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APPLICATFOR LIQUID WASTE PERMIT SAN'JOAOUII )HTY PUBLIC HEALTH SERVICES - ENVIRitR„•AENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOCKf'ON.CA 9MI-M i7t"5}49�-(1'54Vtj {209}488.3420 LL �Hu1'i!F-• NON•REFUNDABIE PERMIT EXPIRES 1 YEAR FROM DATE lSSU ED ICamplete In Tr1pRRBUPI APPLICATION la HERESY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED,THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAOUIH COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110.3 AND THE STANDARDS OF SAN JDADUIN COUNTY PUBLIC HEALTH BERVICEB,ENVIRONMENTAL HEALTH DIVISION. 3e4-.AC S ADDRESSIOR APNR 705 o D RA 14 l2'C1{ cnv_"PRf1�Y A - LOT SIZE OWNER'S NAME b. ADDRESS 45 FD czn_ 7-,,hc C FHONE,(z eaS-`i o3 CONTRACTOR W/a+-`TPR _ C.UTtiT'IS. __AObAE88A'i9 MA�'la 'N PL1gZ{j_�09} C -LICIT C'' II? PHONEIZd��C.�i�`t+�7 Cl'�1L Tet^!G1 NE's�TL SUB CONTRACTOR ADDRESS UCN PHONE t a7✓ TYPE OF SEPTIC WORK: NEW INBTALLATION REr untAbt"noN ❑ DESTRUCTION❑ 3 F"lr-s ILIO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET aP SUILDIN6.1 PERC TESiI•I f]HOW MANY Applig0on s INSTALLATION MULSERVE: RESIDENCE COMMERCIAL❑ OTHER 13 fINRl 12 OL} - 9,rEALDJf G OtA NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYM: 0'3/'ju/o l) -IZ-nQ CHARACTER OF BOR TO A DEPTH OF 3 FEET: PTIGUMP BOIL CHARACTER: WATER TABLE DEPTH ;'ic'JK SEPTIC TANKMAEASE TMP ❑TYPEJMF6 CAPACITY NO.COMPARTMENT PKO TREATMENT PLANT 17 DISTANCE TO NEMEST: WELL FOUNDATION FFOPERTT'LINE-RT-f•EIVE❑ LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHINO LINE ❑ M.6 LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION�y�;��,(��T��gPFT H FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION "PRDPEA�Y V r MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION-NP59 '{111HE11 INTY SEEPAGE HTS ❑DEPTH 812E NUMDER DISTANCE TO NEAREST:WELL FOVNOAMN pubo" f��V1CL�'S IItEMil lti Hr I:ITTTR4 - BLAMPS [3 WIOTIR LENGTH DEPTH DISTANCE TO HEAREBT:WELLFOVHDATroN PROPERTY LINE DISPOSAL PONOS 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HERESY CERTIFY THAI t HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGUATIONB OFT HE GAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORIC Tan WHICH THIS PERMIT 18 RGSVEO.1 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 FOLLOVANO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOIKMAN'S CDMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPLETE ORAWING BELOW. ii 1 SIONEO X TITLE: 1'lL1L- i"-K{_i i 1+1 it DATE: i�rz�l-- ROT PLAN IDRNW TO SCALE)SCALE 'Ro 1,NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE 010POOAL SYSTEMS. 3, DIMENBIONEO OUTUNEO AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES,_ ii.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.ANO WAIxe. THE PROPERTY OR ADJOINING PROPERTY. .... .. ......, _ �� alN>r LECEIip L � S L� ❑-RFHxe T ' '� O."CE.S.t-Ho!E= I_CX./1T10y5 - TL '�^ri '� a 'C ccdrn ,I -{'aLSrs:-T^clliaY �I V t. s "A A � ATLSCK l� ?AR[FL3 3 a PARCEL-L n , ..... :. ... I -I hLG P•pr MR CEL ..i yr .. el E '.... - 4� I: PARCEL ¢ I uc nuns I.a /'T C III OEPARTMEHT UB [[�ONLY APPLICATION ACCEPTED BY ,L(I^ DATE: �"[J U AREA! =pvTANK,PT OR SUMP INSPECTION BY DATE . I I _FINAL INSPECTION BY GATE ADDITIONAL COMMENf6: - � —O ACCOUNHNO ONIY: MON FAC/ PE CbOE FEE LNFO AMOUNT RITMITTED CHECKOP:ABH RECEIVED BY DATE $R I PERMIT NUMBER INVOICE R