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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N.SAN JOAQUiN ST.,STOCKTON,CA 962010300 ;2081 468-3420 NONREFUNDABLE PERMIT UPIRES 1 YEAR FROM DATE 13SUED Xaftpl1b IS Tripbast l AMUCATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMn TO CONSTRICT ANDMA INSTALL THE WON(DESCRIBED. THIS APPLICATION B MADE N COMFUANCE WITH SAN JOAQUIN COUNTY OEVFIOPMENNTTITLE CHAMER9-11 10.3-_AND THE Sl"DARDS Of SAN JOAQUIN COUNTY PUBLIC HEALTH BERNCS,ENVTFONMENTAL HEALTH DMSION JOBADDRESS.T)VAFNVAI✓71 Y0,#y7r^' /P 0-!I• LO. T&:E 757AOWNER'6NME=�N CRPVGA` ' � r z s ADORE.SS 4lOF3 PMaME!yNE�/y am,- �Q l.L, / 2 CONTRACTOR I S r! /SDN AOOREE.09�'N. Wr L SOn! t,�JA y Lx. S'4 3 4t RHDNe�1LG"IG,sC�F'7' SUB CONTACTOR ADDRESS LJCP PANE TYPE OF SEPTIC WORK NEW INATALLATION 13 RIPAIVADOITION 7L OE1fRt1CTION Q INC SEPTIC SYSTEM PEPMOTED I'PUBLIC SrWER IS AVAILABLE WITHIN 200 FEET Of SUILDMG.I O'N MANY INSTALLATION WILL SERVE: FESIOEIICE IO COMMERCIAL❑ OTHER NLMNOt OF WIND UNIT■ NUMS9IOIF IIEDROOOMNm: S: NwMSm Of I IAY CHARACTER Of SOIL TU A DEPTH OF I31 FEET.A C1 IM gFEZ Pf,ww SOIL CHAMCIER:. WATER TABLE DEPTH '7:5 �y SEPTIC TANG OIIEASE TRAP DITYPEIL CAPACITY NOCOMPAJITVFNTS l- MO TREATMENT PANT❑ DISTANCE TO NEAREST WELL FOUNDATION FAORERrY EINE UFT STATION❑ 817E TYPE Of PUMP SAND OR SEPARATOR(ENCLOSED SYSTEMI A� � IEACNNO UNE a NO.\LENGTH OF LINES_� -' IS /K�-NG DISTANCE TO NEAREST:WELL 2%�'t- fOUNDA.fpN '?'_PNDP'E11'TY IRIS S FILTER am WIDTH LENGTI: DEPTH DISTANCE TO NEAMST:WELL.F(%1N'JATION PROPFlfTY LINE - MOUNDED ❑'MOTH LENGTH DEPTH /J DISTANCE 70 NEAREST:WELL Mi,NDATION PROPERTY UNE SEEFAOE SRS DEPTH t 01:E f7!! NUMBER f+ „DISTANCE TO IFAREST,�FJUHOATpN PROPERTY LNE4(0• UP/O� SUJPS Iy0IWIDIH LENGTH__OEPIN DISTANCE TO NEAREST.WELL _FOUNDATION PMFERTY UNE OIy IPO\AL SE3 ONGS WIDTH LENGTH _DEPTH DISTANCE TO NEAREST.WEU__FOUNDATION PROPERTY UNE I HFREBY CFIITIFYTHAT 1 NAVE PREPARED THI8 APPLICATION ANO THAT THE WORK WILL BF DONE N ACCOrb ANCE WRN FAN JDAOWN COUNTY ORDMANCES AND STATE LAWS,AND MASS AND REGULA IONS OF THE SAN JOAQUIN COUNTY.HOMEOWNER OR U.ENSED AGENT'S SIGNATURE CERTIFIES T HE FOLLOY.INO',•1 CERTIFY THAT INTHE KWOPMMKE Of THE WOM FORNMICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO SECOME SUBJECT TO WOMMAN'S COMPENSATION LAWS Of CALIFORNIA.' CONTP4 TDR'S REBID OR tx SIIFCONTRACT LNG SIGNATURE CERTIFIES THF FOLLOWING:-1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOP WHCH THIS PETMITT IS ISSUED.1 SMALL EMIPLDY REASONS SUIJECT TO WORKMAN'S U.PENSATION LAWS OF CAI IF0". ' TME APPLICANT MWT CALL N NODU IN ADVAMCS PORI ALL AVO ZD NSPICTIONS. COMPLETE DFIAVWM BELOW. SIGNED TITLE:�r -NL DATE:4- 'F6 ^ PLOT PLAN(DRAW 10 SCALE)SCALE__-to 1,NAMLS CP STALE I S UH ROADS NEAREST 10 OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTINE OF TALL 1'ROPERTV.WITH DIMENSIONS ANO NORFM DIRECTION. EKPANBLORI Of SEWAGE DISPOSAL SYSTEMS. J OIMLNSION:D V.;IINtS AND IUCATION OF ALL EXISTING AND PROW SED STRUCT UFYS. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNORED FIFTY FT.ON INCLUDING COYER%L AAEAS SUCH AS PATIOS,DRIVEWAYS.AND WALAS. THE PROPERTY OR ADJOINING P10P'FNTY. SIF• frI• 1 _M' 7O' LCA•:N DRAIN' � .. .- ` •lNVSL L A.'rl NI 1 I I � - .. _w_FIi .12'.rJLEAe1( " :�. ,1fi. 'SO'-d'- 4 i .. M ... A v(M Q I•• IE�AL iER-I MK1 I u Ire }J` 1t r rI►l Y Alirry MAY 2 9:1996 IJCGUdI ON/OBI\Bbl .� --I-I I "Li8L1CHEALTh}SEPVI E: aFVIaEF� I t 1 � ' LNvIAUNMENITAL HEALTH c VISI(,, FOR DEPARTMENT IIS&ONLY APPLICATION ACCEPTED BY /�. DATE: ALFA Z IS 7 TANK,PTT OR SUMP INS,-ECTION 8Y DATE ! p I( FINAL INSPECTION ADDITIONAL COMMENTS: 3�-`� Nom+ /'lac. - �AtV F�e�.T F-GcJ rf',•` $ �yiK.� -� 30IV' 'gCfU�-, J - C0 ACCOUNTNO ONLY. p}pP FACJ PE COW FEE 1 AMOUNT ROMrTED IFC !CASH RmUVm■Y DATE SR I P9RWT NWS[# INVOICI"s Oa I W