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APPLICATION FOR LIQUID WASTE PERMIT ) l SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES S c GPTIC ENVIRONMENTAL SION RO,BOX 388,304 EAST WEBER AVENUES ITOCKTON.CA SMI (209)468.3420EP 1 '^ (ION-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUER 1 (� (Complete M Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMT TO CONSTRUCT ANOAR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT THELE,CHAPTER 8.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR API/ 1 1 / / 1 J� P-- ':j 5%j ^. /�C— �p(j-t- LOT SIZE'-90F+ ER' p OWNS NAME �f-I •J--T3Y'?M �7 r-. ADDRESS I J p1 / / 10)(2 1 YY• `` PHONE CONTRACTOR �.�- C -N ADDRESS / f) ,r,'�;,�•�, PJ1v� UCO' SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF IF►OC WORK: NEW INSTALLATION E3 REPAIRIADOETION❑ DFATROCTON❑ KA SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET Of BUILDING.) PEIC TFSTT+1 11110W MANY APPH-0-J INCTALLATION WILL SERVE: RESIDENCE® COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITA:_ I_NUMIOR OF RFDROOMa: 3 NUMBER DF EMPLOYEES: CHARACTER OF SOIL TOA DEPTH OF 3 FEET: C.1 AM PITISUMP SOIL CHARACTER:.C��,�1*� ;J WATER TABLE DEPTH -):.> SEPTIC TANKPOREASE TRAP 13TYPFJMFO ('nlO C-/ m FZa CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION ? PROPERTY UNE—Lao 1 RIFT STATION❑ SIZE TYPE OF PttU'� AN MP SD OIL SEPARATOR IENCLOS D SYSTEM) LEACHING LINE 19 NO.♦LENGTH OF U LINES ) SL �O DISTANCE TO NFAREBT:WELL J CCe' FOUNDATION a-c , PROPERTY LINE 6— / FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UIE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY UHE SEVAOE RGk"TS 19 DEPTH 5-N BRE L-of`' NUMBER DISTANCE TO NEAREST:WELL • FOUNDATION_ I U O PHOPEATY UNE SUMPS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WROTH LENOTM DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOWWILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:*1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR MUCH THIS PERMIT IS ISSUED,I&HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORLMAN'e COMPENBATON LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERWW( CERTIFIES THE FOLLOWING:'T CERTIFY THAT IN THE PERFORMANCE OF THE OFOR WHICH THIS PERMIT 18 ISSUED,1 SEIALL EMPLOY PERSONS SUSJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. / -{1�I SIGNED X J--) (J`1 (!-;,+151 TITLE: IL-7 rlw-z�Q DATE: / PLOT PIAN(DRAW TO SCALEI SCALE 're IIIfLJJI��\ 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE—P`7 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I\ 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED StRUCTIREQ, 6,LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ... ... �\ (?..... _I... .. .�.1� R11 ..... _ .. rvv J, r _ GAN'FQAQ`'LHS3 I1)1 NUI... pONNFN _.: .Ems. .• :. :. :. ..:. .. ..:._._._. _. ... . .. . .. : ._.. :. ... FOR DEPARTMENT USE ONLY A'PLICATION ACCEPTED By �(n DATE: AREA',-,26 2 J1 OR BUMP INSPECTION BY DATE ) 6�£IN AL INSPECTION BY DATE ) J 1 v ADDITIONAL COMMENTS: ACCOUN11140 ONLY: AID( FACS PE CODE FEE INFO AMOUNT REMTTrD CHECK/ ASH RECEIVED BY DATE INVOICE/ T q� . a L