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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 9520143BB (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICNTIpl81R E TlylisatO APPLICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY FORA PERM" TO CONSTRUCT ANO.OR INSTALL THE Y40W DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WTI'N SAN JOAOUSV COUNTY DEVELOPMENT TITLE, CHAPTER 0-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRES6,00K APPNO l p� Y�y�FTF��j/y.��rQ` Y U e . Clry (V� A T e C /� LOr GlZj OWNER'S NAME l I I"'V 4- M IV IL F� p4 A 4, 13- D � NJO f � G PHONE Z96 ADD - COHTMCTOR�Q� MtMv RESS LICI PiOMf BUB CONTRACTOR ADDRESS UCO PRONE TYPE OF BEPTIC WORK: NEW INSTALLATION ❑ REPANUADDLTON DESTRUCTION ❑ NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABEF WITHIN 200 FEET OF BUILDING.( FB1C 7ESTb1 [ 1 NOW MANY INSTALLATION WILL BONE: RESIDENCE Ct COMMERCIAL ❑ OTHER ❑ NUMBER OF LINO UNITS; / NMYREI OF BE-7-/MEi NIA1/OE Of YIIMOYm CHARACTER OF BOIL TO A DEPTH OF 3 FEET: -n-"- � - /, PF/SUMP BOIL CHARACTER: /(,00 WATER TABLE DEPTH --L SEPTIC YANKIORfAK TRAP ❑ TYPEAEFG L VT G G Q I'L C • CAYACFTY pQ 1 NO. COMPARTMENTS FILO TREATMENT PLANT ❑ DISTANCE TO N&EREAT: WELL FOUNDATION IMPERTY IME LIFT STATION ❑ SIZE TVP: Of MP BAND OIL SEPjj��R1''//�TOR (ENCLOSED SYSTEM) _ ' LEACHING ENE DG'�O. A LENGTH OF 11NE8 L - z-' I rDISTANCE TO NEAREST: WELL / FOUNDA.TION_� PNOPERTY UNE T FILTER BED ❑WROTH LENGA DEPTH DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE MOUNDED ❑ WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE SEEPAGE NTS ❑ U DEPTH SIZE__ NUMBER DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY NE BUMPS 0 WIDTH LENGTH__ DEPTH DISTANCE TO NEAREST: WELT _ FOUNDATION PROPERTY UNE DISPOSAL PONDS E)WIDTH LENGTH _DEPTH DISTANCE TO NEAREST: MU. -_FOUNDATION PRROPERTYUNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR( WILL BE DONE IN ACCORDANCE WITH RAN JOAQUIN COUNTY ORDINANCES AND RATE LAWS. AND RULES AND REGULATIONS Of THE RAN JOAQUIN COUNTY. HOMEOWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOYANO: 'I C EPTTIFY THAT IN THE PERFORIMANCE OF THE WORK FOR WHICH THIS KAMR 18 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 SUBCONTRACTING SIGNATURE CETTTFIESTHE FOLLOWING: 'I CERTIFY Th AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WOPKM ANF CAL1fORNIA.' THE AFPUC ANT MW T CALL IA NOURB IN ADVANCE FOR ALL �RE'GIARED INSPECTIONS DR ECTIONS. COMPLETE AWING BELOW. SIGNED )( TITLE:_ F JWfi6 /` DATE: QCT / y 7 PLOT PLAN TO SCAL:I SCALE W 1. NAME F STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPORED 2. OUTLINE OF THE PROPERTY. WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUWG AND LOCATION OF ALL EMITTING AND PROPOSED STRUCTUR:6. 6. LOCATION OF WELLS WITHIN RLADIUB OF ONE HUNDRED FIFTY FT. ON INCLUDING COVEPFD APE CH AS PATIOS. DRIVEWAYS. AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 46 13 le- L�^ r 8 Ib� Gp�Lo�P f �QO � ou.e O 1 S dL O Q¢sT S l leap F� Ae- R:►PY kN A MENT -u-T 6 1991 - � �� _ � 1^ �. � ✓l � �'- 7 � " � SAid IOAOUINCLiUN ES -. �� _ of lal lC 1EAl.TN s��1 SIC1N �NVIPUNI� FOR DEPAATMENT MAE ONLY RZ7APPLICATION ACCEPTED R`; DATE: f O - APIA: TANK, IRT OR BUMP INSPECTION BY/ DATE ! 1 FINAL INSPECTION BY DATE 10 1 L I 1 AOUMONAL COMMENT 8: I 4 S (`�. D'( ae HLA ACCDu1TINa ONLY: AID( FACI PE—OF FEE INFO I AMOUNT REMITTED CHECKP N ROCOVED BY DATE M I PERMIT MUMMER INVOICE O s6 o gg (SA Oo 13868