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4 r. t APPLICATION FOR LIQUID WASTE PERMIT 71 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NONREFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED (Complete in Tripliast8l APPLICATION IB HEREBY MADE TO THE GAN JOAOUIN COUNTY FOR A PERQMrr TO CONSTRUCT AND/OR INSTALL THE WOFIL DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TTI�M CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. LOT SIZE (1J( JOS AODRE8810R A�PN�N., .��j"�1 �/� � � ��/---�Q��t-A�� -_ -- - CITY�/� f� ` OWNER'S NAME 3aEy!:1 6-e f4 Ct W_ NODS S 6 PHONE 3(0 - tt SS�7 J vc'G it lLIC ADDRESS r�Q� FJOVi � S �- r fJr PHONE '77 f}�`i CONTRAC70R __ SUS CONTRACTOR ADDRESS UCO PHONE TYPE OF SEPTIC WORK:. NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER ISA LADLE WITHIN 200 FEET OF BUILDING.) FERC TE8ThJ I 1 HOW MANY APpNw+Ren INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: 'I NUMBER OF BEDROOMS: L4 NUMBER OF EMPLOYEES: i CHARACTER OF SOIL TO A DEPTH OF3FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPT" �.�r Opy SEPTIC TANK/OREASE TRAP Lk-7k/MFG _. _. _CAPACrTY I. NO,COMPARTMENTS 'f PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) i LEACHING LIME LI-IN-0.A LENGTH OF LINES �zn DISTANCE TO NEAREST:WELL i 2)n�1 FOUNDATION PROPERTY LINE ferr FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED �1❑vo H LENGTH_DEPTH DISTANCE TO NEAREST:WELL. FOUNDATION PROPERTY UNE � SEEPAGE PI7d SCI DEPTHy„BtZE NUMBER DISTANCE TO NEAREST:WELL. FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL. FOUNDATION PROPERTY LINE OISPO$AL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:11 CERTIFYTHAT IN THE PERFORMANCE OF TH15WORK FORYNRCH THIS PERMIT IS ISSUED,I$HALL NOT,&IPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFONdA.- CONTRACTOR'S HIRING OR sus-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIR£D INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE:r A 1 _.-_.- DATE: ` 7L , PLOT PIAN IDRAW TO SCALE)SCALE -to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE 04SPOM 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, G. 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. .... .......... ...... ... ... _ - .., .......... .. ..:..... . . ... ... h. ......... ...... . . � r .. .. .. .. :. .:. ... .. .. �..:�.. Q i... .. ... . .. . .. .. .. .. .. ... - $ . �g9 .. . � ... ...... �� wr .:.. .... .... }"fQ qq ON ...._.............;.., .. . .........:... .:.............:........... .. -_ ...... l .FOR'RPARRTMENT UBE ONLY . qq ///�''',,;//// ♦/ I APPLICATION ACCEPTED BY DATE: '2/ - AREA: -rA AVT } V OR SUMP INSkL TIOIN BY DATE ! ! FINAL INSPECTION BY DATE ! 1 ADDITIONAL COMMENTS: 2 ✓ << / '�'�� ACCOUNTING ONLY: ALDf FACE PE CODE FEE INFO AMOUNT R9MIITED15I ,CASH REC9VE0 BY DATE SR I P91MIT NUMBER INVOICE 0 Pub.Health Saw.-Enviro.174(3/96)