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_ APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 488-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complttt in Triplktttl Ay, APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MAbE IATOMPJANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER 9-11yy10��.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTRIDISRBION. JOB ADDRESSIOR AMO ICJ 3 0) /�yyJ,Q F f E-1 T (j z 1,t)" CITY Al A N I L-C 'J Y4 ,^{ P l n T LO SIZE_ OWNER'S NAME ar Co � ve 1? 1 l L7 1 ADDRESS �/�� Jh �) PHONE- CONTRACTOR ' CONTRACTOR ICoc4NI RLu In b nr ADDRESS 143,? t �L`tSC '1�n111/Q/ A / UCA -20 %' RIONE47U�lU SUB CONTRACTOR ADDRESS IA V U VLTY UCI PHONE 4)6 oG 6 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPMR/ADDITION DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN POO FEET OF SUILDING.1 PPRC TEITNI 1 1 HOW MANY APWm.a•D s INSTALLATION L SERVE COMMERCIAL 11 OTHER 0 NUMBER OF UVINOUNITS: NUMBER OF BEDIMDOms' NUMBER OF EMPLOYEES: _ CHARACTER OF SOIL TO A DEPTH OFTK3�E�FEET: �h/�L{� RT/SUMP BOIL CHARACTER:_ WATER TABLE DEPTH �l��- O SEPTIC TANK/OREASE TRAP -PEIAFO FXY(7� TANK—CAPACITY_-f �r NO.COMPARTMENTS �2 C�� PKO TREATMENT RANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE O UFT STATION Cl 81 7 E TYPE OF PUMP_�lSE SAND OIL -SEPARATOR(ENCLOSED SYSTEM) LEACHINGD UNE . NO.A LENGTH OF LINfB 1g I /• 7��t-I�DIBTAHCE TO NEAREST:WELL bO L_r MUNDATION Fr PA PERTY UNE U FT. RLTER BEG ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 1 DISPOtAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULL9 AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WO W FOR WHICH THIS PERMIT 1S ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'8 HIRING 0 BUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKS AN'S COM EN ATIO 8 OF CALIFORNIA.- HE APPLICANT MUST CALL N HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING NO BELOW, y TRLE: Y.7�l IL."//✓C�� q-L� h AOT PLAN(DRAW TO SCALE)SCALE 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING 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 EXISTING AND PROPOSED STRUCTURES, B. 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. -(ICY N.1 tS Q v, - PAYIUIENT, RECEl11M +- SEP 2 31997 10 � ` r SAN JOA LIN CCUNI': PUBLIC H LTH SERVICES LL. Z Y FNVIR0NN/Et11 L HEALTH DIVISION CIO ni T II FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: Z-3 AREA: / 1 TANK,PT OR SUMP INSPECTION SV /) DATE / / FINAL INSPECTION BY DATE' ADDITIONAL COMMENTS: Q CG� ACCOUNTING ONLY: AIDE FACF PECODE FEE INFO AMOUNT REMITTED CHEC (CASH RECEIVED BY DATE NL/PEIMMIT NUMBER INVOICE• 0 3 oyl �a �