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T APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388,904 EAST WEBER AVENUE,STOCKTON,CA 8b2piS88 <br /> (208)4683420 <br /> RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRON DATE ISSUED <br /> C <br /> APPUCATIDN 19 HEREBY MADE TO THE BAN JOAOUN COUNTY FOR A PERMIT TO CONP ( , <br /> STRUCT INSTALL STALL THE WORK DESCRIBED. THIS APRJCATION 18 MADE N COMPLIANCE VAM SAN <br /> JOAOUW COUNTY DEVELOPMENT TITLE,CHAPTER 11 1110.3 ANDD�T14EE STANDARDS OF SAN JOAQUIIN'ECCOOIMTY PUBLIC HEALTH S VICES,ENVINONMEHTAL HEALTH OMBION. <br /> JOB ADORE9Spq ARI# 4 u' �y eD L LI 1 CI7y� lOi&ZEy���� <br /> OWNER'S NAME F�../V! 7,Z O4` � ,�. / l? ''j �" Qom^ <br /> ADORE88 J / / �� PHONE /��7-Q J�� <br /> CONTRACTOR ADOAES9 LIC# ._ <br /> PHONE <br /> SUB CONTRACTOR :74 1 <br /> ADDRESS27 ��j .�'^��'� <br /> �# PTIDNE-�Z...-L.11_L <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ RIPPANUADINTION❑ Mr luCnoN❑ <br /> NO SEPTIC SYSTEM PERMRTED IF PUWC SEWER IS AVAILABLE WITHIN 200 FEET OF SUILONO.) ►NIC TEATW(1 NOW MANY <br /> ADPIIoNIen <br /> INSTALLATION WILL BENE RESIDENCE COMMERCIAL❑ OTHER❑ <br /> NUMBER OF LIVING WTS:_ / NIUMSBI 0 SEOROOMS: NIANSER OF BIIPLOfffff/////YYY�YYYFF�F�YYY���(f(jj�� ((,,ffll�y�y]]�((((,,,fffyII��,�##]]](p((JJ))JJJJJ � <br /> CHARACTER OF SOK TO A DEPTH OF 3 FEET: CP SUMP It.CHARACTER: WATER TABLE OEPTNL <br /> SEPTIC TANKIOREASf TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS ` <br /> PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL / <br /> FOUNDATION PROPERTY UNE <br /> LIFT STATION❑ SIZE TYPE OF RUMP $A/NDD OIL SEPARATOR(ENCLOSED SYSTEM( <br /> LEACMNO UNE NO.S LENGTH Or UHES_-3 5'�U 6/`T T INSTANCE TO NEAREW:WELL /60 FOUNDATION_ENIppERFy tlNE� O_ <br /> FILTER SED ❑WIDTH LDMTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PRDEEMY UNE <br /> MOUNDED ❑WTOTH LENGTH DEPTH INSTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE_ <br /> SEEPAGE PRS RDEM;�SIZE NUNbEA DISTANCE 1.HIAF£BT:WEE.L FOUNDATION PROPERTY LJNE_ <br /> SUMPS ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINT C <br /> DISPOSAL FONDS ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNOATION PROPERTY LEVE e <br /> I HERESY CERTIFY THAT I NAVE PREPAPED THIS APNICATION AND THAT THE WORK WILL tlE DONE IN ACCORDANCE WITH SAN JOAOUN COUNTY ORDINANCES AND STATE LAWS,AND <br /> RRULES <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOVNNO:'I CERTIFY THAT N THE POW40F MANCE OF THE WORK FOR WHH <br /> THIS PENMT IS ISSUED,I SHALL.NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOALMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING"'OR <br /> SVBCONTRACTNG SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS EERM7T IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORMA.' THE APPLICANT MWT CALL 24 HOURS IN ADVANCE FOR ALL REGUIRIED INAPECTONS. COMPLETE DRAWING BELOW. <br /> SIGNED X <br /> TITLE DATE: <br /> .1 <br /> ROT MN IDPAW TO SCALE]SCALE 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PEIOPERTY. 4. LOCATION OF HOVSf SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PIOIEFrry,WRH Don""NONS AND <br /> NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANO PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN PAD"OF ONE HUNDRED FIFTY FT.ON r <br /> INCLUDING COVEIEO AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS, THE PROPERTY OR ADJOINING PROPERTY, \� <br /> 7S� d L�tr <br /> M <br /> �U <br /> FOR DEPARTMENT USE ONLY / <br /> APPLH'ATION ACCEPTED SY DATE: I AREA. 2l <br /> TANK,PTT OR BVMW INSPECTION BY DATE / / FINAL NSPEC KION BY OATS O Iff <br /> AOORZONAL COMMENTS:. <br /> ACCOUNTING ONLY: AID! FRCP <br /> PE CODE FEE INFO AMOUNT REMITTED CHECIV/CASH RECFOVm BY DATE EI/PERMIT NUMBER RNOKE f <br /> Zit 5 O-" 16117 he D <br /> S0.oa A n k 6 <br />