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APPLICATION FOR LIQUID WASTE PERMIT -AN JOAQUIN COUNTY PUBLIC HEALTH SERVICE.-- ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 962010388 (209) 4683420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Tripliuto) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPl E T TITLE,CHAP�(TXR 9-1119-3 D THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, VIRONM AL HEALTH DIVISION. JOB ADDRESSOR APNB J Y' / /J/ 7 ✓) .� f ��.LL� / CITY _X�C✓177 LOT SIZE_ l OWNER'S NAME / 4(-'464a2 ADDRESS /JPHONE CONTRACTOR ADDRESS C,lS /��f,. YN r — 13__G y uca, PHONE . D P � SUB CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADDITION ❑ DESTRUCTION ❑ ONO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER I6 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERO TESTI.)1 I NOW MANY ApglPatlon INSTALLATION WILL SERVE: RESIDENCE 11 COMMERCIAL Ur— OTHER 13 NUMBER OF LIVING UNITS:_ NUMBER OF SEDROO B: NUMBER OF EMPLOYEES: CHARACTER OF 601E TO A DEPTH OF 3 FEET: "L/M1 JY PIT/SUMP SOIL CHARACTER: �I WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY I F+I16-^ / '✓..C>C' NO.COMPARTMENTS h MO TREATMENT PLANT❑ DISTANCE TO NEAREJIT: WELLU> J FOUNDATIONPROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP STAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE 13 W.A LENGTH OF LINEST:_ A-— /FD'— LA I DISTANCE TO NEAREST:WELL A C70 JPOUNDATH)N40 V PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTYUNIE— SEEPAGE RTS ❑DEPTHS v/$I,�Z NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 'ham ,QY,TI'IENGTHy DEPTH DISTANCE TO NEAREST:WELL, f/ ' "IFOUNDATION�- 'i^ PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OOFTHEWOIK FORWHICH— THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- /THE A�PPPLLICANT MUST CALL 24 HOURS IN ADVANCE FO/R/tALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW�. SIGNED% U I I ! ji17I,'l.V l//✓� TITLE: DATE: �-1 RAT PLAN(DRAW TO SCALE)SCALE 'ro 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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 E%ISTINCI 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. 17 t 4t --- - - vT UI I T_1-3 ' - I ,. T' D y> / (/FOR DEPARTMENT USE ONLY q APPKICATION ACCEPTED BY / �-�C p (/��rJ �'////111(/Jy DATE: •✓� �� E AREA: / /,f V OR SUMP INSPECTION BY )� �// GATE (&U'RNAL INSPECTION BV DATE:C /Zt1/T J (ADDITIONAL COMMENTS: J ACCOUNTING ONLY: AD# FAC# PE CODE FEE INFO AMOUNT REMITTED C KNCASH I RECEIVED BY DATE SR I PERMIT NUMBER INVOICE Y r� d-�