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C'NPPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 384 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)4"-3420 N ON•REFUNDABLE PIE RNLI EXPIRES YEAR FROM DATE,ISSUED O(OUDV (Complete In TripRala} APPLICATION 18 HEREBY MAGE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN SLIC HEALTH SERVICES.ENMENTAL HEALTH DIVISION. JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND STAND SAN JOAQUIN COUNTY PUNVI M t CRY /�'V LOT SIZE (� JOB ADDRESS/OR AP/N�I rJ PHONE OWNER'S NAME i.�"�` ' AOORE88 Ary (�{A�t L-Z�pl{ONE �3 CONTRACTOR Qrx./ �7N ADDRESS ` �.'Il• -�,� :i UCf . tICI _PHONE, ADDRESS SUB CONTRACTOR NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION❑ TYPE OF SEPTIC WORK: FERO TESTh)1 I NOW MANY ILIO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) Appsa�Sen! INSTALLATION WILL SERVE: RESIDENC�COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITS-- I NUMBER OF BEDROOM$: NUMBER OF BVIPLO PITJSUMP SOIL CHARACTER. WATER TABU DEPT OF SOIL TO A DEPTH OF]FEET: NO.COMPARTMENTS C TAN E TRAP ❑TYPEIMFO "�^"' CAPACITY ENT RANT❑ DISTANCE TO NEWEST: WELL FOUNOATFON +_ PROS uNE l 4� r fi 3 TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) ^ I I y LIFT STATION❑ 81ZE^�,.. � 2�+PROPERTY UNE N� T' yll.'. DISTANCE 70 NEAREST:WELL LINE__ .�— LEACHING LINE �NO.a LENGTH OF LINES FOUNDATION- PROPERTY LINE FILTER BED !!❑WIDTH IENOTH DEPTH DISTANCE TO NEAREST-WELL FOUNDATION PROPERTY LINE, MOUNDED �`rr❑��--YVI��OT..HLENGTH DEPTH OISTANGE TO NEAREST:WELL�� aUNDATION��4-PROPERTY LINE �� SEEPAGE Pira � '��812E I t _NUMBER I& DISTANCE TO NEAREST:WELL._ BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE�.� DISPOSAL PONDS ❑WIDTH IENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LJNE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDIHANCEB AND STATE 1J1W8,AND RULES ) AND REGULATIONS OF THE SAH JOAOUIN COUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOYVING:'I CERT[FY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT Is ISSUED,I SHALL NOT EMPLOY COU ANY PERSON SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING 0R , sue.CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING' CERTIFY THAT IN THE PERFORMANCE Of THE WOR%TOR WHICH THIS PERMIT 19 ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO ` WOIKMAn's CO ION LAWS CALIfORNIA.' CANT MUST CALL 21 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW PATE: SIGNED X T"U:: �...,/ W TO LOCALE) 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE E DISPOAGESAL DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE Of THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS• Y h 9. 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,DRIVEWAYS,AND WALKS, THE PROPERTY OR ADJOINING PROPERTY. f ��, S ..... P - .. ..',.. .. ...... ....... :. . . .....' ..... .. ............ �( .. .. _a :r-. FOR DEPARTMENT USE OE 111 DATE: 7_ APPLICATION ACCEPTED BY r— JG AREA: f i �OR SUMP INSPECTION BY DATE F..J 0 FINAL INSPECTION" DATE CPI ! 6-6 ADDTIONALCOMMENTS: �C �-t~,- �� Z ®O ACCOUNTING ONLY: AID( FAG - 77 PE COPE FEE INFO AMOUNT REMItTEO OIIEC (CASH RECEIVED BY DATE 811!PERMIT NUMBER INVOICE 690 z Pub.Health Serv,-ERvirD.174(3196) 1