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APPLICATION FOR LIQUID W(om�PERMIT SAN-JOAQUIN COUNTY PUBLIC 1,. -10 SERVICES ENVIRONMENTAL HEALTH DIVISION SCANNED P.O.BOX 3B8,304 EAST WEBER AVENUE,STOCKT'ON,CA 95201 988 (209?468.3420 ROWNEFUNDAM PERMIT EXPIRES I YEAR FROM DATE ISSUED [Complete In Triplicate) APPLICATION IB tIEREBY MADE TO THE SAN JOAQUIN COUNTY FON APTNWY TO CONSTRUCT ANDMFI INSTALL THE WORK DESCRMED• THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY aEUFLaPMENT TITLE.CHAPTER 8-1110.3 AND 711E GTANDAMS OF SAN JOAQUIN COUNTY PUBLIC$4EALTH SERVICES,ENVIRONMENTAL HEALTH ORSSION. - JOB ADORESMR APNT C4TY� rL,�..?". �_IAT SIZE_<.d2!&s OWNER'S NAME I � AODREBS $itmg- —mom-_.--__-- mom Ply- 4Q V9 CONTRACTOR AOORESB ?U! �1 {/,+//fes•• :12-JCC~ LILT'�JS'rYd PRONE ��'S��`7 I SUB CONTRACTOR ADDRESS LICA mom k TYPE OF SEPTIC WORK: NEW INSTALLATION TLLPAnvADOTTTON 0 bTyT11UCTION 13 IAO SEPTIC SYSTEM PERMITTED S PUBLIC SEWER IS AVAILABLE WITHIN 2DO FEET OF SUILDINO.1 PERC TESTUt I 1 NOW MANY [� APPeoPKPn S L MSTALLATION WILL SENIS RESIDENCE fil COMMERCIAL O OTHER NUMBTIt OP WINO UNITS: I NW IIIER OF BEDROOMA.-- ----NUMBER OF NIIIPLOYMM: 1 CHARACTER OF SOIL TO A DEPTH OF 3 FEET: r&4 PITISUMP SOIL CHARhCTMR dAA I WATER TABLE bEPTTI r 5G SEPTIC TANK)=EAeE TRAP ❑TE/MFa Gt,-j CAPACITY ff, O �� L YI' NO.COMPARTMENTS PKO TREATMENT PLANT CI IKSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LSIJ T STATION SIZE TYPE OF PUMP SAND OR.SEPARATORVXLOSEO"EMR LEACHNO ME NO.a LENGTH OF LINES OIBTANCE TD ItEA3E6T:WELL 1 7�=FOUNDATION SO. PLWPtl1TY UN£ , N FILTER BED E3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPMY UNE r MOUNDEP D WIDTH LENGTH OEPTIt DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE„ SMPAOE PETS DEPTH S, SIM J6„ NUMBEi�_,DISTANCE TO HEARFBT:MRLIJ 7C�, FOUNDATION 9'PROPERTY LINE�� SUMPS ❑WIDTH LENGTH DEPT" DISTANCE TO HEAVIEST:WELL FOUNDATION PROPERTY Lim c DISPOSAL PONDS 13 WIDTH LENGTH DEPTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE r I HERESY CERTIFY THAT I HAVE PREPARED TILS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OIIDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOEW'S 8I0NAT4RiE CERTIFIED THE FOUOWHNO:9 CERTIFYTHATIN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMrt IS MM13,t SHALL NOT EMPLOY ANY PERSON IN SUCH A MAMMAS TO BECOME SUBJECYTD WDIKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HmMO OR SU&CONTRACTING SIGNATURE CERTOTES THE TOLLOVYMO;'I CERTWY THAT tN THE PERFONIMLCE OF T14E WORK FOR WHICH THIS PERMIT 10 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MINT CALL 114(OURS M ADVANCE FOR ALL RAMMED INeFECriONs-COMPLETE DRAVVU40 BELOW. C- SIGNED X 1001- _TILE: (�s.a.�a�G DATE: AOT PLAN BMAW 70 SCALEI SCALE 'to 1.NAMES OF STREETS OR ROAM NFAREST TO OR SOUNDING THE PROPERTY. 4.LOCATION OF HDUBE SEWAGE DISPOSAL SYSTEM OR PROPOSED Y.OUTLINE of THE PROPERTY,KITH OIMEN1MG AND NORTH Dn1ECTI&N. EKPAMMN OP SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN RADIUS OF*HE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS OUCH AS PATIOS,DRIVEWAYS,AND WALLS. THE PROPERTY OR ADJOINING PROPERTY. ..... ....,_.. ..... , .. .. .. .. . .... - .. .. ......... -....... ............ --.- ... M lob .... .._ _ :...` 1 -s pq ..01 sAX 4+ r 14 .. FOR DEPARTMENT USE ONLY 'y A""P""P___U"""��/CATION ACCEPTER BY �j_�.J '�A ->3 / (.. -. - DATE: �7 JJ REA: L t C��OR SUMP INSPECTION BY'�kT.!!.•��/J-3..d �r DATE /�7 -F1HAL R49KCTION BY -L"- DAT 1 AbbTrION11NAL COMMENTS: IF v ACCOUNTING ONLY; AIO1 TAC1 v !E COBE FEE INFO AMOUNT REMITTED CNEC ASN RECEIVED BY DATE SR I m NUMBER INVOICE S PE:q t i:s- s 41$0-- L,6 1011 t q S c Q n ni h�l114