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APPLICATION FOR LIQUID WASTE PERMIT INS SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 r (209) 4883420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CemplEts in TrOlieatel INS, APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH I JOAQUIN COUNTY DEVELD.MEW TITLE,CHAPTER 9-1110.3 AND THE STANDARDS Of BAN JOAQU'INN COUNTY PUBLIC HEALTH SER CES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN/j� ( � A !\n'2n± 1/��/ - ✓Lm, ,�/ ra�_wn�cj LOT SIZE /.5 r OWNER'S NAME C_ /I/L� U �-t-t'�I-• ADDRESS�✓C/ c C[./ (�c�F.ryJ ^�z cka�s _v PHONE 7 CONTRACTOR •J -�C�—tf[g-t_ ��'�1 j(_ ADDRESS/--/ C- CSL -A SUB SUB CONTRACTOR ADDRESS LOi PHONE TYPE OF SEPTIC WORK: NEW INSTAlUVON REPAIR/ADOITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC 5FWER IS A ILABLE WITHIN 200 FEET OF SUILDINO.I FERC TIAT(SI I I HOW MANY us APPawBen P INSTALLATION WILL BMW: RESIDENCE COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS:_L NUMBERIOOF/BEDROOMS: � NUMBER OF EAKOVam— CNgTI , R OF SOIL TO A DEPTH OF 3 FEET / ,�--yL�s'��+t��'�Y�YYYi¢TT(lS^VMP 901E,/CHARACTER: //fiS/ WATER TABLE DEPTH! �C9 / 6 C T OREAAE TRAP ❑TYPEII.LFO L1•s4&LZZL-�.rLA.Q(+�R CAPACITY h A>�Y— NO.COMPARTMENTS l WO TREATMENT PLANT❑ DISTANCE TO NEMIJIT: WELL t FOVNOATION � f PROPERTY UNE 1J UFT STATION❑ SIZE TYPE OF PUMPSAND OIL SEPARATOR(ENCLOSED SYSTEM) �7 r LEACHING UNE ;w NO.i LENGTH OF LINES :3'—'YL,i �i'LJZe DISTANCE TO NEAREST:WELL/(90 FOUNDATIONl pgpERry LINE FILTER BLD WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH ^z DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE RTS DEPTH T SIZES NUMBER J DISTANCE TO NEAREST:WELL ZS D fFOUNOATK)N I 9— P OwfRrY UNE r� SUMPS ❑WIDTH LENGTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONOS ❑"DTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATIONND THAT THE WORE WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND"ATE LAWS,AND RUL AND REGULATIONS OF THE SAN JOAQUIN COUNTY'.HOMED R DR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THEWOW FORWHI THIS PERMR 18 ISSUED,I SHA MPOY ANY PERSON CH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING SUB{ 71NG S 1 B THE PoLLOWIN 'I ERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT WO MAN'S C STI U OF ALIFOR CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSMIRONS. COMPETE DRAWING BELOW. 1 SIGNS Vp1C TITLE, ,B_ � DATE: POT PLAN(DRAW TO SCALE)SCALE 'to I. 1. NAMES OF STREETS OR WAGS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS All NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.R INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. L{0 y i..