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. t APPLICATIOLF,OR LIQUID WASTE PERMIT a SAN'JOAQUIN;F 'TTY PIrSLIC HEALTH SERVICES A ENVIRON.-,,NTAL HEALTH DIVISION P.O.BOX 388,904 EAST VVEBER AVENUE,STOCKTON,CA SMI,'A8 12891468.3420 AWREFUNDAB E PERMIT EXPIRES 1 YEAR FRO Ii DATE ISSUED t MempIStm in T*Ikmtm) APPLICATION IS HEREBY MADE TO THE DAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANGIOS INSTALL THE WORN DEBCRIDED.THIS APPLICATION 10 MADE IN COMPLIANCE WTTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH BERVICEB.ENVIRONMENTAL HEALTH DIVISION:-' 5 JOB ADOREesroH nrLa'2.S$—' Z cS:k bU _ crrv. LOT SIZE OVjt1IER'r NRME j L — ADDRESS 4-G g ISPHOHE 211 Cu(- .1 19VA CONTRACTOR ADDRESS LIG/ PHONE SUB CONTRACTOR ADDIQSe UC' PHONE 1 TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAITUADOITION❑ DESTRUCTION❑ / -1 (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTH111M HOW MANY } II INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL E3 OTHER© P£�CQLX�-I-I�♦.L RE/�plty[7��II ^I`LJ/y�'��p"I NUMBER OF NUMBER UNITS: NUMBER OF BEDROOMS: NUBEt OF EMPLOYEE!: v- li�DN EFsb y'1 - CHARACTER OF SOIL TO A DEPTH OF 2 FEET: PLTIBUMP SOIL CHARACTER: WATER TABLE DEPTH n' I SEPTIC TANIUGRTASE TRAP ❑TYPFJMFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: wELL FOUNDATION PROPERTY LINE LIPT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR&NCLOSED SYSTEMI LEACISNG UNE 13 NO.B LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIN{ FILTER BED D WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PnDPERTY UNE 6EEPAOE RTS LJryDEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MUMPS D WIDTH LENGTH DEPTN DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANDREGULATIONSDF THE SAN JOAQUIN COUNTY.HOMEOWNEROR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT INTHE PERFORMANCE OFTNE WORK FOR WHICH THIS PERMIT 18 ISSUED.I BNALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.' CONTRACTOR'S HIIIING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTrtY THAT tN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO ' WOFKMAWR COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOLISM IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE D14AWOlG BELOW. ' SIGNED X ---.. TITLE: c-1YIL t-zt4r_ ;1,1 _DATE: C�' � 6z 4:SMk €W PLAZf'+bLo�uNloRCiLwT+ `�ALE�i�AiE IAC? AIS ,P - (Z>9)3 5-4-159 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 ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMB.. I 3.DIMENSIONED OUTLINES AND LOCATION OF ALA,EXHITING AND PROPOSED STHIICTUBEG, S.LOCATION OF WELLS WITHIN RAb1118 OF ONE HUNUPEo FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRVLYIAYS,AND wAULO, ��y,.� THE PROPERTY OR ADJOINING PROPERTY . v 1r LA1WCAJ\'1 C :� ►w - �e 1 f�P7 7! I f kl 7{�hR +IFI i r mct A tn, i tee€ . .. 4 T ... so i I !.. x ,.. �`Ae sti FtL ... I... 14lRQnr;r vyA�f i sav�i-�f�p-n l ... S .... FOR DEPARTMENT USE ONLY ,�UU /�gg AMICATN)N ACCEPTED BY DATE: AREA: O .y TANK,PIT 0R E SUMP INSPECTION BY DATI ! FRENAL INSPECTION BY DATE IwI ADDITIONAL COMMENTS: 1•� 5,E4 ACCOVNTNO ONLY: AID' V FAC. PE CODE FEE INFO AMOUNT REMITTEDCHEC ASH RECEIVED BY DATE SR t PERMIT NUMBER INVOICE' Z Z 445.. 19O C