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APPLICATION FOR LIQUID WASTE PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br />(21191490-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 TEAR FROM GATE ISSUED <br />(Caaglete In Triplicate) <br />APPLICATION IN HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CON97RUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IN MADE IN COMPLIANCE WITH SAN <br />JOAOUM COUNTY DEVELOPMENT TITLE, CHAPTER 9--111110.3 AND THE <br />LR/,TANDAPDS F 'Al y�.K1�A, DU� COUNTY PUBLIC HEALTH /SERVICES, EN%VI�R�ONME/NJTAL HEALTH DI VIFAH. <br />lDe ADDRFegroR AAv/ j f� q j I') C lrt EI � )11121-',x,. CITY ` QC�CCP�'r LFA /tot 84zEgi10— <br />C.WNER'6 yAME `/r� z. tZ ADDRESS �}�A 1� ��// / PF1fiNE W I 7 <br />CONTRACTOR rT.�v� ''� L. ADORFSe / GI `. r•,/TL L —NEE 7 <br />SUBCONTRACTOR <br />PHONE <br />TYPE OF SEPTIC WORK NEW INSTALLATION REPAIRIADDITION ❑ b"TRUCTIDN ❑ <br />IND SEPTIC SYSTEM PERMTREO IF PUL`l1C SEWER Ri AVAILABLE WRHIN 700 FEET OF BIRLDNKT.I L P91C TpT11l I 1 NOW MANY <br />J AppnaeSap I <br />INSTALLATION WILL 16IVE: RESIDENCE L COMMERCIAL ❑ OTHER ❑ <br />NUMBQR OF LIVING UNITS: 3 <br />� NUMRM O► BEDROOM/: NUMNNR OF PAPLO/YEE6: <br />C OF SOIL TO A DEPTH OF 3 FEET- MTMJMP SO CHARACT£1! WATER TABLE DEPTH �e / !A <br />((�, //� l <br />EPTIC TA FAAE TRAP ❑ TYPENWArG� �. [nl C{.- CAPACIT'' 'L� l+ NO. COFaPARTAIENTS� <br />PKa TREATMENT PUNT ❑ bISTANC9 TO NEAREST: ' WELL11=l FOUNDATION__ ffwr?mrY LINE ?� <br />UFT STATION ❑ySSIZE TYPE OF .'UMP, / BAND OIL SEPARAtOR IFNCLOSED SYSTEMI <br />LEAU,CISNO NE 7U NO 3 LENGTH OF UNES�_ YCI I ��n�..� DreTANCE TO NFARFOT� WEEL-P e t FOUNDATION PROPERTY LINE <br />/ <br />F7—IJV <br />LTBR SED ❑WIDTH LENGTH__ DEPTH DISTANCE i0 NEAREST- WELL__ FOUNbAtON PROPERTY UNE <br />MOUNDED ❑ IMDtH LENGTH DEPTH DISTANCE 70 NEAREST: WELL FOUNDATION PROPERTY LINE <br />•[iPAOE PITA DEPTH = I 512E ' I 1 T _ NUMBER 3 INSTANCE TO NEAREST: WELL r� <br />,2�T U <br />FDUHDATIOH S� I PROPERTY NE S E`E� <br />SUMPS, �❑III WIDTH LENGTH OEPFII DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />D16POeAl PONDS I--1 WIDTH LENGTH UPP-r" DISTANCE TO NEAREST: WELL- FOUNDATION PROPERTY LWE <br />HEREBY CEATIF`/ THAT HAVE PREPARED THIS APPLICATION AND THAT Ti <br />llILL SE DONE IN ACCORDANCE 11H SAN JOAOUIN COUNTY ORDINANCES ANO STATE UW6, ANO RUlE6 <br />AND REGULATIONS OF THE SAN JOAOVIN COVNTY. HOME OWNER OR LICENSIGNATURE CFRTFIE9THE rOLLOWINO:'I CERTIFYT14AT IN THEPERFOFRMANCE Of THE WORKFOAYFCHr <br />THIS PERMIT IS ISSUED. 1 T EMPL ANV PERSON IN SUCH A MABECOME SUBJECT TO WOPe(MAN'9 COMPENSATION LAWS Of CALIFORNIA' CONTRACTOTYS HIRING OR -✓ <br />SV9C0 7U RE CERTIFIES FO LLOWMIO: "1 CERTIF`/THWORMANCE OF THE WOiK FOR WHICH TMB PERA/ri IS It19UE0. I SHALL EMPLOY PMBONB SUBJECT TOWO AA�C <br />ROH U S APPLICANT ARHOURS M ADVANCE FOR ALL REQUIRED RUFECTWNS. COMPLETE DRAWING BELOW. <br />6. NFO X T.LE: �{T Vim{ DATE:_ <br />/ PLOT RMI STRAW TO SCALEI SCANLE ' <br />1. NAMES OF STREETS OR ROADS NEAREST TO UNDINO THE PROPERTY, 4. LOCATION OF HOUSE SEWAOF DISPOSAL SYSTEM ON PROPDSEO <br />2. OUTLINE OF THE PROPERTY, WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM8. <br />3. DIMENSIONEb OUTLS'IES AND LOCATION Of ALL EXISTING AND PROPOSEo STRUCTURES. 6_ LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON <br />INCLUDING COVERED AREAS SUCH A9 PATIOS, DRIVEWAYS, AND WALKS. — PFenPFsrry 11 11-- m.ccaTv <br />FOR DEPARTMENT 1166 ONLY <br />AP++R KATION ACC EPT'O BY �� DATF; '� ✓�I/) [, / /� AREA:�Z 12— <br />(rh��- SUM' •I6PEC TION B� ?".AlnATrTINSPECTION BYDATE <br />ADDITIONAL C'F"ENTR: <br />ACCO'JNTINO ONLY'. AIDI FACA <br />PZ CODE FEE INFO AMOUNT REMITTED CNE W ASH RECEIVED by DATE <br />6N 1 P6OWT MIMSEiI INVOICE F '1 <br />t 5 a <br />~ <br />0-/-793 <br />�Rool34' <br />