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kv 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 95201.0388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FRUIR GATE ISSUED ICompletb in Tripikatel APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPIJA!4CE WITH SAN JOAOUMI COUNTY DEVELOPMENT T``TfLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNN_ 1 _,l �'I L V .. ^_CITY �� _LOT SIZE 12�. OWNER'S NAME �C0L1'4 U>�ir—}1 ADDRESS RSd-P �� "��'T fj�l�- �3�4yL=A PHONE19 3Le-3X w� CONTRACTOR P-LSI] ADDRESS 1 LICE PHONE SUBCONTRACTOR �y 1�� AppRE86 �� LICE _PHONE TYPE OF SEPTIC WORK: NEIN INSTALLATION REFAuvADdT10N ❑ DESTRUCTION ❑ iNO SEPTIC SYSTEM PERMITTED IF PUBO:SEWER IS AVAILABLE WITHIN 200 FEET OF BINLDING.Y FERC TESTW 1 i NOW MANY Appllw-Son# INSTALLATION WILLSFIME: RESIDENCE❑ COMMERCIAL❑ OTHER❑ NUMBER OF OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:. L �7vpGr.-�i CHARACTER OF SOIL TO A DEPTH OF 3 FEET; PITISUMP SOIL CHARACTER: WATER TABLE DEPTH_ SEPTIC TANK/GREASE TRAP ❑TYMWFG CAPACITY NO.COMPAfITMENTB PKG TREATMENT PLANT❑ DISTANCE TO NEAREST, WELL FOUNDATION PROPERTY ME LIFT-STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR[ENCLOSED SYSTEMI LEACHING UNE ❑ NO-&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH __DEPTH DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY UNE SEEPAGE RTS 11DEPTH SIZE_NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPEiRTYLINE DISPOSAL FONDS ❑WIDTH LENGTH DEPTH^ DISTANCE TO NEAREST:WELL �FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE YVM14 SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOIl.OWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THEWORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR RRIALL REQUIRED INSPECT10NS- COMPLETE DRAWING BELOW]. , SIGNED X t (� TrrLF: Ff �I DATE: C ` ! PLOT PLAN{DRAW TO SCALEI SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPAHSiON OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INC', POVFRED AREAS SUCH ALPATI06.DRIyEWAYR.ASID WtLKB. cu LEACH FIELD AREA 016TRI&ff VON soar 15M*AL 51=PriC r ' 7' 5741•r.Mtl� V PiPL~ Ca�C 1104 WWUN fry . V T.WCafQ I I yZC4C�t- veaL�LT w1'S"}1 L � L��FT SSprrlor� �ti�� MAY 18 1919;5 . . . ._. SAN JQAQUiV.C;CJUNTY . . . ... . -- PUBLIC HEALTH SERVICES . ...Era . .. :. :..,..,:.-- FOR DEPI& Q rMI[)NLY APPLICATION ACCEPTED BY DATE: LL A C± ��STIIO TANK,PIT OR SUMP iNSPECTION BY DATE / I FINAL INSPECTION BY DATE'V`�Lf RL, ADDITIONAL COMMENTS: • i� r .s~ .s� /,__ ACCOl1NTING ONLY: AID# FAC# SPE GOOE FEE INFO AMOUNT REMITTED CHECK#lCASN RECEIVED BY DATE ER 1 P6YWIT NUMBER E# �' 44z 0 1