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r APPLICATION FOR LIaUID WASTE PERMITI ,,sAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICFFt 1p ENVIRONMENTAL HEALTN DIVISION R0. 80X 988, 304 EAST WEBER AVEENUE, STOCKTON, CA 95201 " (2091 489.3420 i� lc� t� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR ROIU ATE ISSUED ts In Tr APFyJCATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO COCNSTRIUCT ANDRIIINSTALL THE WORK OESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DF LO ENT TITLE,CHAPTER 9-1110.3 AND TH�� AN AADS OF SAN JO GUIN UNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. - �/fTYY /-Z3o-67 frY� /91-�sfd'- !'�4- AT- JP9 ADDRESS/0R APR# aFL'1S CITY Tv 'Ltj1Q 9 LOT SIZE OWNER'S NAME �S �prps ADDRESS �� CONTRACTOR 7,01PHONE_ ADDRESS LIC# PHONE SUB CONTRACTORAODRE88lIJ P ZS` A 1'!'1 Lo I/ _ S T LIC#Q,PHDkE�7 . TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADdTION D bFxTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF 8UILDING.) PERC TFAT(41 I 1 HOW MANY INSTALLATION WILL SEINE: RESIDENCE© COMMERCIAL ❑ OTHER ❑ APPSeeaan I IL 9-']--- 3 rf NUMBER OF UVINO UNITS; NUMBER OF BEDROOMS: NUMBER OF EMPtOYEE6; dP�7-- CHARACTER OF SOIL TO A DEPTH OF 3 FEET; R SEPTIC TANK/GgFJlBE TRAP 13 TVPf/FAFG PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH CAPACITY ' FR NO.COMPARTMENTS VI ! PKG TREATMENT PLANT 0 DISTANCE TO NEAREST: WELL FOUNDATIONG PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP`SAND OIL SEPARATOR(ENCLOSED SYSTEMI i LEACIBNO UNE ❑ NO.i LENGTH OF LINES DISTANCE TO NEAREST:WELL - 4 FOUNDATIONPROPERTY LINE flLTfA BED D WIDTH ! LENGTH DEPTH DISTANCE TO NEAREST:WELL -FOUNDATION. PROPERTY LINE . . .MOUNDED ❑WIDTH ..` LENGTH DEPTH DISTANCE TO.NEAREST:WELL. — � FOUNDATION PROPERTY LINE 8E6A0E13-DEPTH OEPTH SIZE NUMBER IRSTANCE70kEAREST:WELL - FOUNDATIONPROPERTY UNE SUNK D WIDTH :p _LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONOS (3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE r F HEREBY CERTIFY THAT 1 HAVE PREPARES THIS APF'LICATION.AND THAT THE WORK WILL BE DONE IN ACCORDANCE'WRH BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RVIEe 1 AND REOt1L11T10NSOFTHE SAN JOAQUIN COUNTY.HQMEOWNER ORLICENSED AGENT'S 810HATURECERTIFIESTNEFOLLOWINO:•ICERTIFYTHATINTHE PERFORMANCE OFTHE.WORKFORWHIC{ THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'@'COMPENSATION LAWS OF CALIFORNIA.•'CONTRACTOR'S HIRING OR ! SUBKONTRACTING SIGNATURE CERTIFIES THi?FOLLOWING:•{CERTIFY THAT IN THE PERFORIuIANCE OF THE WORrK FOR WHICH THIS PERMIT IS.IBBUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIlCMAN'B CO NSATION LAWS F RWIA.• THE APPLICANT MUST CALL 24 IIOilms IN ADVANCE FOR AIA.REQUIRED IN BFECT10Ni. COMPLETE DRAWING BELOW. SIGNED X TITLE, �c3C.L1t—pe—. DATE:- PLOT 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED Q 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.O INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. H .; .. .... ., . ..i ..i.... L.,. - ., ..K . � rr� F � , R i S a- ir •y. t R ..,.., ... '. - } e p 199? . . . .. -.. .. ... _SAI .JPRQUIN COUNTY �L V1 Fj3N.+F£NTAL,NEALT1 DIV1S1O�1-- APPLICATION ACCEPTED BY DATE: 0 AREA: TANK,PIT OR SUMP INSPECTION BY �• - DATE_ / 1 FINAL INBPE TION BY DATE +-YYI'l l l 7 k17 ADDITIONAL COMMENTS: r MIL/L-ED AIL 1� ACCOUNTING ONLY: AID# �I - � 'a� FAC# PE CODE FEE INFO AMOUNT REMITTED CK CASH RECvVEDjsx SR I PERMIT"NUMBER INVOICE# �- 0/273 O 8s8