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,-.,NAt`ICATION FOR LIQUID WASTE PERMIT -- y/ SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201.0388 (209) 4883420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Trlplleml APPLICATION IB HEREBY MADE TO THE SMI JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WON(DEWNSED. THIS APPLICATION 18 MADE N COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND LTHHE{S�TANDARD/S,OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESB/OR APN# /-TOO OO Z ��/A L J(:7A �C1ITY nlweyC C��-../`-1 LOT SIZE_ p OWNER'S NAME L J/1 A TR(�JC/ADDRESS �6J�// E 4b (JeYA PHONE, CJ'6>S�+�L7pI CONTRACTOR / / r ADDRESS '///� UCI PHONE SUB CONTRACTOR /�/ ��/L/_Y' ADDRESS I �LCTf=/ Cil LIC/ ��LIF��ONE / TYPE OF SEPTIC WORK: NEW INSTALLATION jo REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMNTEO IF PUSUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.$ PEO TSSTIEI I I HOW MANY Y \ APpl..g.0 INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL El OTHER ❑ \\ NMMOM OF LUNG UNITS: NUMBER OF BEDROOMS: NUMBER OF WK Eel: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: //////��PIT/SUMP SOIL CHARACTER: WATER T E DEPTH SEPTIC TANK/OREAIE TRAP ❑TYPEIMM L/A.,M CAPACITY NO.COMPARTMENTS ` PKG TREATMENT RANT❑ DISTANCE TO NFMFIT: WELL�y1�IfT MONDATION FT PROPERTY UNI-f_T LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEMI LEACHING UNE ;KNO.L LENGTH OF LINES KO FT DISTANCE TO NEAREST:WELL UNDATION MPERTV LINE�f(Q�� FILTER BED 11WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNOATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE RT/ ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE �• DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES O AND REGULATIONS OF THE SAN MAGUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONIIUCTOR'8 HIRING OR SUB-CONTRACTING 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 m WORKMAN'S COMPENSATITIOONN/LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RSGUIRm INSPECTIONS. COMPLETE DRAWING BEOW.�//� SIGNED K/� / �/{ �� TITLE: e4.,-,W YiLt'J'C/ DATE: PLOT PLAN(DRAW TO SCALEI SCALE -to (T9� 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED Y. 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY PT.ON INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. Q uS�MiTN RD -�-i Jo" PAYMENT RECEIVED MAR 2 199 6Ypj JEJAQUIIJ COUNTY TY 7----�•�� Ttf79LICHEAL1HSER ICES 001R91'OTNTALHFALIH, ASION' /7, o o � I � I I 9J I, Ere. ri r > >r n u Z7 X5. IL nttl t So /•'T SIG 3 �iti/.. _ FOR DEPARTMENT USE ONLY 7 APPLICATION ACCEPTED BY�a ) i DATE: \J AREA: 7— TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION B DATE l y ADDRIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC* PE CODE I FEE INFO AMOUNTREMITTED ®/CASH I RECOVEO BY DATE M/PERMITNUMBER INVOICE