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e, ' i I ,3 APPLICATION FOR LIQUID WASTE PERMIT 1 SAN'JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 988,304 EAST WEBER AVENUE,STOCKTON,CA 95201.388 (209)488.3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED lCompkn In TFfplkaul APALJCATIION 18 HEREBY MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE, TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDS[80/09 APNI �[//p�� ;% ` ��//N ��7Dly'" �nL''/ C/ETV �7\T� LOT 812E , OWNER'S NAME_--Q r�L/,•,�,.A�� j ADDRESS 070 y// /�I.0 T//^' /^�U /l'V PHONE ''I' CONTRACTOR 1 EJI V1L�l y7� - AODRE88PO �y' —I6� G ZQI I LN:#&6t nn 2 RHONE;]7, SUB CONTRACTOR ��/I/1 CJN�OTi(I ADDRESS � 'j LIC0 PHONE TT TYPE OF SEPTIC WORK: NEW IP48TALLATION❑ DITION DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN ZOO FEET OF BUI NO.I PIRC TEST(2I I I HOW MANY �,( ASPSeStlen INSTALLATION WILL SERVE: RESIDENCE{Ol COMMERCIAL❑ OTHER❑ NUMBER OF UVINO UNITS: � NUMISR OF 8 l: MUM8Y1 OF WROYEE//�F{Ip'� CHARACTER OF BOIL TO A DEPTH OF 3 FEET: PIT/SLIMP BOIL CHARACTER: l J W_-(�_ WATER TABLE DEPTH ` SEPTIC TANIUOREASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS PBG TREATMENT PLANT❑ INSTANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP $AZNT��D OIL SEPARATOR(ENCLOSED SV9TEMI LEACHING UNE 11 NO.l LENGTH OF UNES 4 4V/ DISTANCE TO NEAREST:WELL SQ/ FOUNDATION /0-1'- PROPERTY LINE �0 FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH L£NGTN DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE RTS 23`OEPTH SIZE A&E I NUMBER_DISTANCE TO NEAREST:VJEll4fdZ7�I FOUNDATIONlii�PROPERTY LINE /D SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I PREPARED 18 APPUCATON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAGUIN COUNTY OFOINANCE9 AND STATE LAWS,AND RULES AND REGULATIONS OF THE AN JOAWINCO Y.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:*1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WMCH THIS PERMIT 18 ISSUED,1 B ALL NOT EMPLOY PERSON IH SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR quo CONTRACT O 61GNA RE CERTIFIER TH FOLLOWING:'I CERTIfY'THAT IN THE PERFORMANCE Of THE WORC FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM NBATIO LAWS OF CAU NMA.' THE APPLICANT MUST CALL H HOW IN ADVANCE FOR ALL REQUIRED INSPECTION$. COMPLETE DRAWING BELOW. ' SIGNED A Y TITLE: DATE: • PLOT PUN(DRAW TO SCALEI SCALE -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPAN&ON OF SEWAGE DISPOSAL SYSTEMS. O.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON INCLUDING COVERED AREAS SUCH AS PATIOS,DPo S,AND WAUU, THE PROPERTY OR ADJOINING PROPERTY. 1 _ �i l , Alm CJ: IJ ea , �I PAYMENT 71997 :SAN JOAQUIN COUNT(' PUBLIC LTH _.... .... ,. �NVIggNME,NTAL AEALTHIgIViS10fl ZZ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY C DATE: ASAI /// O,�y� TAN(,PIT OR BUMP INSPECTION BV DATE I I RNAL INSPECTION BY DATE /I/ KA ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDE FACS PE CODE FEE INFO AAROUR R.TTED CHEC /CASH REC13VED SY DATE M I PERMIT NLM894 INVOICES D Asa