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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED APFtICAT1ON 18 HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPUANCE WITH BAN JOAQUIN COUNTY DEVELOPMENTT TITLE,CHAPTER 9.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI_ 007-244) 36 4-39 '74 300 N, ELLIOTT RD , CITY ACA HPO c - OWNER'S NAME-13 I LLY J0 I��IC GCC L. I• p p p LOT SIZE J-/-1G q ADDRESS I ( / US H WY-•�gR L_ro��( ,,7cA /�Q PHDCE ;,,7 314145 CONTRACTORdSe�ML7Q �.( pIQZT� `lg'llconEBB 323 W- El_M 5S �DI CA ^ICE 1C163 r PHON BUB CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DES TALK=TION ❑ ING SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDINO.) HITW PC TESTI.)(YTN( 7 O'W�MANY_� INSTALLATION WILL SERVE RESIDENCE 11 COMMERCIAL ❑ OTHER 11APdRoagen/ M`t- 8 o IL}. NUMBFA OF LIVING UNITS: NLIMBEN OF BFOROOMS: NUINBsm OF EMPLO YFFs: O CHARACTER OF SOIL TO A DEPTH OF 7 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH RFPTIC TANK/OAEABE TRAP ❑ TYPE O PKO TREATMENT PLANT 11 DISTANCE TO NEAREST: CAPACITY NO.COMPARTMENTS WELL FOUNDATION LIFT STATION❑ SIZE PROPERTY LINE TYPE OF PUMP LEACBAND OIL SEPARATOR(ENCLOSED SYSTEM) lf NO UNE ❑ NO.6 LENGTH OF LINES ' FLLTfA RED DEPTH DISTANCE TO NEAREST:WELL FOUNDATION T WIDTH LENGTH P'ROP'ERTY UNE DISTANCE TO NEAREST:WELL MOUNDED ❑WIDTH FOUNDATION PROPERTY LINE (— LENGTH DEPTH DISTANCE TO NEAREST:WELL �__.-_ SEEPAGE PITS �]DEPTH FOVNOATION PROPERTY LINE SIZE NUMBER DISTANCE TO NEAREST:WELL ('h SUMPS ❑WIDTH FOUNDATION PROPERTY LINE LENpTH DEPTH DISTANCE TO NEAREST:WELL DISPOSAL PONOS WIDTH FOUNDATION PROPERTY UNE LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT THE WOW(WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULER - AND REGULATIONS E THE SAN JOAQUIN EM COUNTY.HOME OWNER OR LICENSED AGENT'S 91ONATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWCMAN'S COMPENSATION LAWN OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WHICH THIS PERMIT A ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CARL 24 IbUltf IN AOVANC[F-0R All REQUIRED INSPEC"ONg. COMPLETE ALL EMPING BELOW. SIGNED X _ Eric SE 7 - TITLE:C1 IL /- _ DATE: PLOT PLAN(DRAW TO SCALE)SCALE I I) 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. to 217 0 7, OUTLINE OF TNF PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, T. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, ,' LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS. EXPANSION f SEWAGE DISPOSAL SYSTEMS. V S. LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT ON . - -- __-- --_--- -. THE PROPERTY OR ADJOINING PROPERTY. -- :... 8gL-2AA Jo HN `-....:..... t .......... ..,. RO 20 Z d v9 so 4 4 \\S R 6 Pak cem Z APN. 007- �No-38 Z 6AC5 f , 0 J A.P.,v, oo�-24a-39 a '� H � i �- O 53 J � y ° w o b-60 J S- v SV m J � ROA'AL1) I- t I 7 K 17Ay l 1 1 199P S�+N JOAOUIN CL�UiVi'Y MP'LIC ATION ACCEPTED By LTM .....PUBUC.HEA FOR DEPARTMENT USE ONLY Q AHK,PIT OR SUMP INSPECTION BV DATE DATE: ARE=/ —FINAL INSPECTION BY ADDITIONAL COMMENTS: DATE��% ACCOUNTING ONLY• ARO/ -- FAC I PE CODE FEE INFO AMOUNT REMITTED NEC /CASH RECEIVED BY DATE SA/PERMIT NUMBER INVOICE 5qjq