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POW Two; / 1110W MARY ApTSPRSer, s 7CMIOrtert CYCJ '7-040VC- OILS sk-o APPLICATION FOR LIDUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOOI(TON, CA 95201-368 (2091 4084420 NON-REFUNDABLE BEANUTpLPIRES I YEAR FROM CATE ISSUED ICeropktsiiTripiltatal APPLICATION IS 413NE0Y MADE TO THE SAN JCIAOutN CoLINTY FOP A REFKur To corarriuct AND/OR IntsrrAu. THE woRX DESCRIBED. 1110 APPUCATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE CHARTER 0-11 10.3 AND T19'ANOARDS OF SAN JOAOU COUNTY FUNK HEALTH szpvicea, EmmISCriaMENTAL HEALTH DIVHINON. JOB ADORE:WWI APINz 6.760 - die.*4 774,4:6/ LOT STZE4L_TAar. OWNER'S NAME ,Eiett.,sc a 449-14(.1, 44J PHC NE e/ 7 CONTRACTOR 7171Fy. ADD/1E6912/ C (--/;‘,--fe‘f/ LICS 4.0/2?.-r- PHONE 441-j-3 suB CONTRACTOR ADDRESS liCE PHONE TAPE OF 4E71C WORE NEW INSTALLATTON 0 ritrumADDincm 0110 DON 0 NO SEPTIC SYSTEM PERMFTTED IF PUBLIC SEWER Is AVAILABLE WITHIN 200 FEET OF BUIL NG CH PIM TREATMENT PLANT 0 DRETANCE TO NEAREST: WELL p4;' FOUNOATION ,,S--- ' PRoNENTY urtE/00 ' INITALLATION WILL SONE RESIDENCE COMMERCIAL 0 OTHER 0 talialLER OF WING UNITS: / NUMMI 01.;,SED000/AS NINNIES OF EMPLOYEEM LIFT arknom 0 atzt TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTETA1 R OF SOIL TO A DEPTH OF 3 FEETe ' FIT/SUBW SOIL CHARACTER? ADFLEASE TRAP WATER TABLE DEPTH.0- In TYPEPAFOL":6 NO. compAPTIMENTI cApActre 1A:1-e , LEACFMR: USE 0 NO, A LEAKITH OF LINES DISTANCE TO NEAREST- WILL PROPERTY IJNE FILTER SED 0 WIDTH LENGTH_ DEPTH DISTANCE TO NEAPEST: WELL cooltOU:DADA: Nieman' UNE MOUNDED 0 WIDTH LENGTH PtH DISTANCE TO NEAR UN sLEPAGE FITS 0 DEPTH DOE MNUIASEA DISTANCE TO NEAREST: WELL FOUNDA770N PROPERTY UNE EST: WELL FOUNDATION PROPERTY UP* SUMPS 0 WIDTH LENGTH DEPTH DRITANCE TO NEAREST. WELL FOUNDATION PIKREPTY LIME COPCSAL PONDS 0 WIDTH 1040TH DE.P111 INSTANCE TO NEAREST: WELL FOUNDATION PROPENTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION ME) THAT Tlif WORK WILL EN DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS, AND PULES AND REGULATE:Ws or THE SAN JoAcsAN COUNTY. HOME OWNER ORLIKENSED AGENT'S SIONATWIE CERTIf KS THE TOLLOwINa: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK PORWHICH THIS PERMIT IS ISSUED, I WALL NOT EMPLOY ANY PERSON SUCH A MANNER 00 10 BECOME SUBJECT TO WONLIAAN'S COMPENSATION LAWS OP CM_XFORNIA.• CONTRACTOR'S HIFINIT Ofl SUP-CO CE THE FOLLOWING CERTIFY THAT IN THE PERFORSAM+CE OF 714E WORK FOR WHICH THIS PERMIT 111 teem, I SHAU. EMPLOY PERSONS SUBJECT TO WOIWIIANS OMPE OF C y ...ANT MUST CAL:. 34 NOUN/ ID ADVANCE FUR AU otteriume, INIPECTIONS. COMPLETE DAAvvirgo sazw. cAu-f PLOT PLAN foRAIN TO SCALE SCALE N NAMES OF STREETS OR ROADS NEAREST TO OFT BOUNDING THE PROPERTY. OUTLINE OF THE PROPERTY. WITH DOMENSKWil AND NoRTH DIFIECTION, DIMENSIONED OUTLAWS AND LOCATION OF ALL EXPSTING AND PROPOSED STRUCTURES INCLUDING COVERED AREAS SUCH Al PATIOS, DRIVEWAYS 0110 WALKS. • 9 . ... : .... ... . , a b 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRONDEIED EXPANSION OF SEWAOE DISPOSAL SYSTEMS. N. LOCATION OF WELLS WITHIN RADIUS Of ONE HUNDITED FIFTY FT. ON THE PROPERTY opt ADJOINING PROFERTy. - ({LA r?_4:7( CX..4,[43-1-t-n PAYmeNT cREcove) . Stetk../LJAPint PLIESIJC Ft SE NVFION'iNiftt,IToz , &Tr : CE$ ,,,c,vtgtroi;te FOR DEPARTMENT USF ONLY TANK, PIT OR SUMP INSPECTION BY ADOITIONAL COMMENTS: APPLICATION ACCEPTED BY DATE (0 t b-11-1 / 6 DOTE 41 IA' FINAL ISPECTTON SY DATE e 0-41 i. .4sc .4 1134/ C15' •k. • . Acct. urertNa ONLY AMA 1 FAG/ PE CODE PER INFO AMOUNT /KNITTED //CASHBISCAY= BY DATE AR i NNW PIUMIER ME— IINDICE 4 Lt 2, i 0 (I 5 (go 0 & / ovidrke ....._s_g_00,,,,„__ )