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APPLICATION FOR LIQUID WASTE PERMIT _ SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION LSP_-96 � 304 EAST WEBER AVENUE, STOCKTON, CA 9520 AY.( z09-i90-11 , (209)468.3420 Bul�-D i tAcd gti f2 M i NON-REFUNDABLE PERMIT PIRES I YEAH FROM DATE ISSUED 9BOO78 1 (CemplBts M Triplkals) APPLICATION 18 HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. T14I8 APPLICATION 19 MADE MPUANCE WITH SAN JOAOWN COUNTY DEVELOPMENT TrTLE.CHAPTER 9-1110.3 ANO THE STANDARDS OF BAN JOAQUIN COUNTY IVISIO PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DN. JOB ADOPESGIOR APN/ i(//01 O 1 V1f E _r-, „LIE R(�/� ([TT �J`�._,,.Cny Q� LOT SIZE Q�(] OWNER'S NAME ADDRESS ,.,,AC PAM�I`J PNONE(910 Zz J^�-�(. wLG(�M c. {�-�a�� OVRFRAGTpR S. CLJ(r'r`�y ADDRESS UC# PlrL PHONE�2 O.9t8--4i SUB CONTRACTOR ADDRESS UC# PHONE. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ INNG SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC T93TIf1�C HOW MANY �1`�C +•Oµ zr-r App*mdon INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER❑ NUMBER OF UVINO UNITS; I NUMBER OF 11I0ftoms; NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET; PITISUMP BOIL CHARACTER; WATER TABLE DEPTH SEPTIC TANKA EASE TRAP ❑T11PElMFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACHING UNE 13NO.A LENGTH OF LINED DISTANCE TO NEAREST;WELLFOUNDATION PROPERTY LINE FILTER BED 0 WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION_ PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PITT 13 DEPTH SIZE NUMBER INSTANCE TO NEAREST;WELL FOUNDATIONPROPERTY UNE BUMPS 13 WIAN DTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATION&OF THE BANJOAOWNCOUNTY.HOMEOWNERORLICIENSEDAGENT'9SIGNATURECERTIFIESTHEFOLLOWSNG:'ICVMFYTHATINTHEPERFORMANCEOFTHEWOIKFORWHICH 1- TM9 PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON M MUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SKINATURE CERTIFIES THE FOLLOWING:"T CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 49 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO �1 WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REUME7 INSPECTIONS. COMPLETE DRAWING BELOW. ry cam'#f1SB F SIGNED X `� �, .... TITLE:.C 01'i L— E 4C' l N,-F:,i�„R. DATE: 2-12--99 PLOT PLAN(DRAW TO SCALE)SCALE_ •Ie 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 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. 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. .. _ .........,.,. ... :. -- - -- .. ... _ .. .. ...,.....i... :... .., ..........:..... .:- .. . .. PAY h fi P�-vor ..... ..... ...,.:.. .. ... .. ., ., .. .. .. .. .. ., .. . .. ? �.... rEB 1 2 1999 :... . f .. A .. ... . ... SAn t.OAQ(JifJC(jt'�!"i: PllBllL Wf=�SLTr-rSCF#tilC��. :ENVIROh(MN1:q�kij l'y- fJIViS ,........... - , — _ _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: AREA: o TANK.PIT OR SUMP INSY_IECTPOF4 BY DATE ! ! FINAL INSPECTION 13 DATE ADDITIONAL COMMENTS: "f r 41, ui Ar /y tia ACCOUNTING ONLY: AID# FAC# PE COVE EE INFO AMOUNT REMIITED fCABH RECEWED BY DATE BR I PERMIT NUMBER INVOICE 0 Pleb.Health Serv.-EnvirO.174(3196)