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APPLICA'� OR LIQUID WASTE PERMIT SAN JOADU14 ,OTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,445 N.SAN JOADUIN ST.,STOCKTON,CA 95201,0388 (209)480.3420 NON•REFUNDRBLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete im Triplicate) APPLICATION HI HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOPOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHANTER9--1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVIGFDN. JOB AbbREBEAR APNF //W Ctry �LC� LOT SIZE u D- OWNER'S NAME AOOPF85 11�E J*Z 5AN DIS 16 Ii TACT`L Cr PHONE CONTRACTOR Don! C N I>�S N ADDRESS D• �01C 3-74�TUIZLG /C LICP PHONE 574�� BUD CONTRACTOR ADDRESS LKF PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ RSPA11yAOm1ION❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMTT7ED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF 81 PERC TESTHI I I HOW MANY APPIUntlaR INSTALLATION WILL SOM: RESIDENCE❑ COMMERCIAL❑ OTHER❑ NVMBSR OF LMNG LNI NUMBER OF BEDROOMS: NUMBER OF IMPLOYEES: CHARACTER OF SOILTO A DEPTH OF 3 FEET: PRISUMP SOIL CHARACTER: WATER TABLE DEPTH SFTTIC TANNIpIEA"TRAP ❑TYPE/MFG CAPACITY NO,COMPARTMENTS FINDTIIEATMEiT PANT IJ DISTANCE TO NEAREST: WELLFOUNDATION E'ROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACHING LINE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOLNIOED ❑WIDTH LENGTH DEPFH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE TS ❑ SEEPAGE RDEPTH BRE NUMDER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE RUMPS ❑WIDTH LFNGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIbTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HERESY CERTIFY THAT I HAVE PREPARED THIS APPIICATION AND THAT THE WOPL WILL BE DONE IN ACCORDANCE YWTH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES \`` AND REGULATIONS OFTHE GAN JOAQUINCOUNTY.HOME OWNER ORUCENSEDAGENT'G SIGNATURE CERTIFIES THEFOLLOWINO:'ICERTIFYTHAT INTHEPERFORMANCEOF THEWOW FORWHICH THIS PERMIT IG I55UED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOTECMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SEGHATU�CERTIFIE5 THE FOLLOIMNO:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WDFK FOR WHICH THIS PERMIT IS ISSUED,I&HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPLNSA7 WS OF CALIF 1 NE APPLICANT MUST CAU'2 HOURS m AWANCE FOR�ALLLL REQUIRED INSPECTIONS. COMPLETE DIMWING BELOW. SIGNED)I_ TITLE: J E^'N DATE: � O ROT RAN 01I SCALL)SCALE 'W- 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PRO PTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POPOSEO 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPDSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO AND PWPOSED STRUCTUSES, - 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON CLUDI o COVERED AREAS SUAS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY• INCH AD MOL I O FFL CE ... UcGATION A L .... 5 Z PAYMEi�' O� 4 I D , _.. .. - AN JJ L)l,iN C')IJN t'UBUC I IFA(TH SEn`I t: ��(JV FOR DEPARTMENT USE ONLY C DATE: 0 1 A' APPLICATION ACCEPTED BY ATE I I FINAL DATE:INSPET ON BY TP �^ I TAM(,RqT OR SUMP INSPECTBV r ADDITIONAL COMMENTS: ACCOUT IXO ONLY: lUW PACK PE CODE FEE INFO AMOUNT REMITTED CHECKA ASH RECEIVER BY DATE SR I PERMIT NUMBER INVOICE {22$ 2-10