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APPLICATION FOR LIQUID WASTE PERMIT S JOAQUIN COUNTY PUBLIC HEALTH (ICES ENVIRONMENTAL HEALTH DMSION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 + '�• (209)468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED gomplote iR TTlplier: 1) APPLICATION IS HEREBY MME TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AHDIDR INSTALL THE WORK DESCRIBED, THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAGUM COUNTY DEVELOPMENT TM.E,CHAPTER 5-11 10.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICER.ENVIRONMENTAL HEALTH DIVISION. JOB ADORESSIOR APNS //zq/ .es �r CITY 4 j LOT$12E OWNER'S NAME IO Q L- _-ADDRESS �/O/ tea. / C: PHONE /` CRNTRACTOR ADDRESS z / J Ld ` L1GI PH0 7 33 b�523 w. Oak f . d� SUB CONTRACTOR ADDRESS LICs PHONE TYPE OF SEPTIC WORK- NEW INSTALLATION D REPAIRfADDIT1011 ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC WMR 16 AVAILABLE WfTHIN 200 FEET OF BVILDING.i PERC TESTA)1 1 Wn!!MANY AWI-Wne MOTALLATION WILLSERVE: RESIDENCE❑. COMMERCIAL❑ OTHER❑ NUM 13 R OF WINO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES- CHARACTER OF SOIL TO A DEPTH OF 3 FEET: FTTISUMF'SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TAN KANtEASE TRAP D TYPEIMF FPKG TREATMENTPLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPS"LIRE i UFT STATION 13 SIZE TYPE OF PUMP SAND O0.SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.a LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE Ffrf FILTER BEP ❑WIDTH LENGTH DEPTH DISTANCE T9 NEAREST:WELL FOUNDATION PROPERTY LIRE ! MOUNDED C3 WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINES ' 4 :?.. SEEPAGE PITS ❑DEPTH ORE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMM O WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIN . DISPOSAL PONOS ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE -r 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGWJITIONSOFTHE SAN JOAQUINCOUNTY.HOMEOWNER OR LICENSED AOENT'SSIGNATURE CERTIFIESTHE FOLLOWING.'10ERTIFYTHATINTHE PERFORMANCE OFTHEWOPKFORWMCH THIS PERMIT 19 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 IBM".I SHALL EMPLOY PERSONS SUBJECT TO WDIKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REO"RED INSPECTMNS. COMPLETE DRAWING BELOW. I X TITLE: OC DATE• l/ `7 "- 8 ` r IDMW TO SCALE) 1. NAMES OF 9tRPETS OR ROADS NEAREST TO 2um::""N'PROPERTY. t. LOCATION OF HOUSE EEWMLE DISPOSAL SYSTEM OR PRDPOBED I _ 2. OUTLINE OF THE PROPERTY.VAIN DIMENSIONS AND NORTH DIRECTION. EXPANSION N F SEWAGE DISPOSAL S OF ONE I 3 DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, O LOCATION OF WR A WITHIN RI4ORIS OF ONE HUNDRED FIFTY FT.ON INCLVOM COVERED AREAS SUCH AS PATIOS.DARMWAYO,AND WALKS. -- - - ............. .... ........._.-.,........ ..,........,.......,.. - -.. THE PROPERTY OR ADJo#fnJo ' _..;.. .. ....;... -�{.. .9 � ... r� I ... : . ,. .. ....... .... .. ...... .... x Nv n�Mt,A� .. F �Ny QT : � q yf{I :..::... . ...:... .. -- .......... .. ..: ........ E.. ..:... -.... - _ ....--:- ......-_. .................- -:-. .. .... ....................... .......... y ............ ...:.... .. .. - .. - .. .. .. - r ---- - - .. .... ..... . . ............. .............. kms, - - ............. - .. .. _- _ ... - ... .. . . -- .-:.......; - ...... .. ......:...... .. .. .. .. - ..