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c A APPLICATION FOR LIQUID WASTE PERMIT ti SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ti ENVIRONMENTAL HEALTH DIVISION 304 EAST WESER AVENUE,STOCKTON,CA 95202 C (209)468-3420 �� NON REFUNDABLE 1`121`12N11EREXPIRES I YEAR FROM DST*ISSUED rAmpMb I/TrlpNws) APPLICATION IS HEREBY MADE TO THE BAN JOAGUN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DESCRIBED,THIN APPLICATION IS MADE N COMPLIANCE WITH BAN 1 JOAOUN COUNTY DEVELOPMENT TTILE,CHAPTER 9-111 .3 AND THE ANDAID/OF BAN JO*OUfN COUNTY PUBLIC HEALTH ' SERCAHEALTH OIWSON. JOB ADMOMR APNI C, LOT RF G O � O03 OWNER'B NAME _ I/ i CONTRACTOR ADORF88 licit PHONE BUB CONTRACTOR ADDRESS LIC• FHONF, TYPE OF SEPTIC WORK: NEW NS7ALLArON❑ RSPANUADDITION DESTRUCTION❑ 1 NOW MANY NO B[PRIC SVSTFU PERWrTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF SUR"NO.I PLIC 76TIN l 1�(AJ AFp/deen/ INSTALLATION WILL SANF: WSIOENCE❑ COMMERC1AJL OTHER❑ NUNAS6t OF WINO LWTS: NIAASEI OF BEDROOMS:y NUMBER OF 6dTEOYSES: CHARACTER OF OIBL TORAP %gr'--_- PITUBUMP SOL C! R: WATER TAME DEPT SEPTIC TANKOR ACTTY NO.COMPARTMENTS PM TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR ENCLOSED SYMMI LEACHNO UNE ❑ NO.6 LENGTH OF LINES DISTANCE TO WAREBT:WELL FOUNDATION PNOPERTY LANE FILTER BED ❑VLIIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATOM PROPERTY UNE SUPAOE R78 ❑D[PrH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SWAP$ 1, 0 WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE LKSPOBAL POND/ ❑VAjY" LENGTH OEF TI 016TANCE TO NEAEST:WELL FOUNDATION PROPERTY UNE - I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAIOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND gEOIAATITINS OF THE BAN JOAOVINCOINTV.NO ME OMMERORUCEHKD AOFNT'6 AONATINE CERTIFESTHE FOLI.OWNO:'ICERYFYTHATNTHE PERFORMANCE OF rHI!WONK FORVAWM THIS IOSIR 1/ISSUED,1 SHALL NOT IN COY ANY PERBDN N SUCH A MANNER AS TO BECOME SUBJPCT TO WORKMAN'S COUNNSATION LIMNS OF CAL;Fgf#d-'CONTRACTON S HSSW Ell SUB.CONTMCTINO WONATU E CFRIEIES THE FOLLOWING:'1 CERTIFY THAT N THE FENMAANCE of THE WDPU FOR WHICH THIS PERMIT IS t/RAO.1 STALL EMPLOY PERSONS SUBJECT TO VVO/KMANS G'OMPEM/ATION LAVH ALMORNLL.' TM APPLICANT MUST CALL 28 HOURS IN ADVANCE PM Ali w INSPECTIONS.COMPLETE OMVNNO BELOW. ✓ `�� )TLE: /1 S . v DATE: SKTNED% PLOT RAN IORAW TO SCALE)SCALE 'In 1.NAMES OF STREETS OR ROADS NEAREST TO ON SOUNDINO THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM lM PROPOSED 2. OUTLINE OF THE PROPERTY.WTTN DRAENRONS AND NORTH DIRECTION. EXPANSION OF 6EWAOE THINDISPRADIUS SYSTEMS. J.DIMENSOIED OURNES AND LOCATION OF ALL[EISTINS AND P10PO9W""C"U'", E.LOCATION OF WELLS ADJOINING RADIV6 OF ONE}PINIONED FIFTY FT.ON MCUANq COWERED AREAS BUCK AS PATIOS.DRIVEWAYS,AND WALLS. TIE PROPERTY OR AlUONINB FIgPFRTY. . ... ........ fT An .. s . ADO .ly`!L G4!'(.. �`'✓ y(T'A dit�i -b rl'.w., .s�d�T 't.',� c"yl, lti1.o'r'/f/r!r r'i l Wil® ?'f b.FS" C-Ar MSE ,.. :.......... .:ff. .....c . ....:...._.. s ..................... .... q .. ak Avv. [,4-rj Lav ........ .. N��t ,. . ........ ,. . . ... "RAJ u fa4Liri,E UN N'S1Etl� 4 M S ..... tT>•1/lRONLF'EWAL HEAALTIi pIV.ISIQh_ .........,.:.. ._: . oh FOR DEPARTMENT UB"S"'ONL 6 APPLICATION ACCEPTED BY Y �^ .Jr�0-/�/ S EN••- cCMA r.-n11-J hAll: W-51 q OfAREA: TALAR•PT OR SUMP SlSPFCTtON By,/•`� DATE I 1_ FlNAL NBPECTON B/V��"^'�,�P - DATE U ! AOO(TIONAL COMMEW.: �F�KT-LEAT}5-w 22_- ACCOUNT!"ORLY: AO. FAC. RAE GOOF FEE INFO AMOWTf IT6A11Tl0 C1rRIl/K BH RECOVER SV DATE M N iEMT BUBI�EI INVOICE I g2fS ZS z ,8/311a mai'{ 2 00 ou z � 95�w o v ///"''YlGOfff a ,,/� Pub.Health Serv.•Enwo.174(3/98) / _,• Q 2-�3- ) _�l�'">7i"""�" -• Gw 5�- 7`1A9 �G ,'{ v�Lsr