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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 9S201-38B (209) 4883420 NONREFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in TrglkEt•) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED, THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/ORA I Dd ��,�nr`1 61) CITY jZ'-'L� �S fOn LOT SIZE_ OWNER'S NAME L r' C C 7 ADDRESS � n �J '�/^� PHONE ��vv(� }�, CONTRACTOR Ln�Q ) 4(S ADDRESS /� W-1 [" +�11L A'n LICJ PHDNE Y/ (�.i /7T� SUB CONigACTOR_ 11.�_r 1�I1,xA00RE66 (�� (�_L17 �O L�"Z� LICI _g10NE 3- - �] E OF SEPTIC WORK. Y NEW INSTALLATION �3 REPNR/ADNT10N ❑ CDESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER I6 AVAILABLE WITHIN 200 FEET OF BUILDING.1 PERK TFAT(.I I 1 HOW MANY ,/ � APNloatlon r INSTALLATION WILL 6D1VE: RESIDENCE VJ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNIT{: ( NUNISIRR OF BEDROOMB:�_ NUMBER OF EMPLOYEE{: CHARACTER OF SOIL TO A DEPTH OFI J?F[ET: A I,,bz. PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASE TRAP LLp TYPERAFO PT � L G {L(i'. C Imo/ TI CAPACY � ry, .. r I NO.COMPARTMENTS PKO TREATMENT PLANT ❑ DISTANCE TO NEA tIAT: 1 WELL I D2_ FOUNDATION 3QI PROPERTYLINE f n�l LIFT STATION❑I-S�IZZE TYPE OF P IMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) -L LEACNNO LINE Le NO.{LENGTH OF LINES —y n' DISTANCE TO NEAREST:WELL— FOUNDATION FOUNDATION InDI PftOfot V LINE FILTER BET( ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE V, MOUNDED 0WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE R �1 SEEPAGE T{ U DEPTHSIZE 3 b, NUMBER_DISTANCE TO NEAREST:WELL FOUNDATIONPROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PRDPERTV UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I 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 REG ULAT IONS OF THE SAN JO AOUIN COUNTY.HOME OWNER OR LIC EN BED AGENT'S SIGNAT USE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEPFOPMANC E OF THE WOW FOR WHICH J THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO�( WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION{, COMPLETE DRAWING BELOW. SIGNED% b"�\ ' L" TITLE: JI�L� %)/�� DATE: PLOT PLAN(DRAW TO SCALEI SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPLRTV. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMSEO 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. D. 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 RgPERTY, `F ul, Li n S rrl 6(pl �_ cav o 0 0'_ � `� - 10 � rE n 11r E FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY Y�2TA �' (/ DATE: I AREA: (a%�P INSPCTION BY (��! GATE !// / FINAL INSPECTION B L. DATE / AL . ENTS: l.Vt. 5 � nnUYI'Y C /)ln"'Vt IT \ ^ (44 ACC.UNTINO ONLY: AID/ FAC# PE CODE FEE INFO AMOUNT RFMITTED CHEC ICASH RECEIVED BY DATE 611/PSNJIIt NUABBI INVOICE Z $ 033 I fZ,