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1 O �0 3 PPLICATION FOR LIQUID WASTE PERMIT SAIIIJOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9520/388 (209) 488-3420 f v7G}�?� S y ' J NOM-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ! f I�GI lCompleu in Tripficatol APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 16 MADE IN COMPLIANCE WITH GAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1110,31 AND 1IIE STANDARDS Or SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORE 66108�APNP� - / � YCiQYL"- C)-{`7- f /^Q'c" _LOT 61ZE4 OWNER'S NAME {�I / 1�,' TJ/ PHONh��L��>,-5�� /7 —� 7 f_i C ONTRAC TQ 9J-1 L»f' ADDRESS IZZ L' �7l��r7 ',� ��J,,i LICP L PI10NE_� (Fn�i n+✓CY SUB CONTRACTOR ADDRESS UCN PHONE TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑ REPAIRIAOOITION ❑ DE@TRUCTION ❑ 1040 SEPTIC SYSTEM PERMITTEU If PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDINO.) PEAC TE$TW I I HOW MANY AppSatlon 4%� INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF UVING UNIT@: NUMOFM OF BEDROOM$: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 9 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP ❑TYPEfMFG CAPACrTY NO.COMPARTMENTS PKG TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER IED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY UNE SEEPAOE PIT@ ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST;WELLFOUNDATION PFIOPERTY UNE SUMPS E]WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE �Q DISPOSAL PONDS ❑WIDTH LENGTH DEPTH{ DISTANCE TO NEAREST:WELL FOUNDATION RTOPEFITY UNE _ l I HEFIEIY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOF@(WILL BE DONE IN ACCORDANCE WITH SAN JOAGWN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATION$OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;"I CERFIFY THAT IN THE PERFORMANCE OF THE WOfW FOR WHICH THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY ANY KF480N IN SUCH A MANNER AS TO BECOME SUBJECT TO WOIKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR CIS SUR CONTRACtINR SIGNATURE CERTIFIES THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO ENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOLM@ IN ADVANCE FOR ALL REOLARED INOPECTION6. COMPLETE DRAWING BELOW. SIGNED X W 'L�ns'"2J TrTLE: 1 �LOL DATE: PLOT PLAN(DRAW TO SCALEI 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. \_ 9. DIMEN64ONED OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED STRUCTURES, 6, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON 1 INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPEFFTY OR ADJOINING PROPERTY. a'w n}o�y ci».arcs Nror aros) ` L FW9R1 4 nLWT Arn h}oYNtl }oo-rl roc acv-w / 5 77']1•]0'E \ fia0.-......._. 5 a9'32-E 1499 5' .... - uor oxpsl 2J \`\ 524 45' ....S 1.45.30'x._. I}UIS z r accwrrx /! 'PARCEL NO. I"°'O'�sI /.• I J 10.00 ACRES 5 2]�T30",w \1 `` D ,`O a, 709.32' S 8'47'30' W r / r.4o.aro+sl �•„ � �1! i'.” PARCEL N0. 2 III 44.6f ACRES S 12-12'30 E 4 If If E 4aO.0' 1I �1 fI N 5TO3' w 5 11'4730" W ``II IJ ►�L/Y��1 fir. Iff1J11I 14 _ 169.0' a._.Hwg 160.0' 11 II I� In1PA G PV EN k Il V E /r�� II i+� T7�,� 17 ,•'r, NOV 1 g SCALE I- _ 700 r1 7"23- w ,: ..1_�� :�,. t vwo „ SAN JOA Q()f�l L'•OUrV i`( n` 47043'11 TCn' _ " ioG`.0 ''"•.-. " 6157- w, ,N I }� PUBLIC HEALTH SERVI( A N i4G.D"... �r� 1I s S67T w > s 4370•W_-' I ..r,° •> R0NMFNlA�..FTEfAtTL:' 1 - 2e+.a'---'� Z `�;a°ln - CIS FOR DEPARTMENT USE ONLY ! L- C,-7 APPLICATION ACCEPTED BY \-4:)V%,- DATE; F REA: z- I `� _ TANK,PIT OR SUMP INSPECTION BY DATE 1 I FINAL INSPECTION BY -DATE /! . r;"�� ADDITIONAL COMMENTS; Po L I ACCOUNTING ONLY: AIOA FACM PE CODE FEE INFO AMOUNT REMITTED CHEC ICASH RECEIVED BY DATE 99 PERMIT NUMBER INVOICE 0 I ,I 34Cv Lp