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APPLICATION FOR LIOUID WASTE PERMIT &--I'JOAOUIN COUNTY PUBLIC HEALTH SERVICES' FILE C ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 466.3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED ICemplata In Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELO 2PMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEERRV110EB,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR�A)PNI� )S?yds � m�l�t� /4'30 UJ mll�-.�Vf— N-UCITy '' ;1 IJGLO P, LOT SIZE t�Z6 OM OWNER'S NAME -k3 b'� LT\V�S`� ADDRE99 � cU3. Ym)w�'Z- -ILL PHONE Z CONTRACTOR �U� -,�/,� ��IC�4 A�SADDnE88�1� SU^O�-�IGSI 3ALn� LIC# ��[ PHONE ?- C1 SUB CONTRACTOR�LIL h1JN 1lS0N �- gs�nC ADDRESS ZZ W. {�J�i�I� LAfjC UC/1"kG 446,0 PNONE(Zo�l3(�-Z-3 10l TYPE OF SEPTIC WORK: NEW INSTALLATIOIIP � REPAIR/ADDITION ❑ DESTRUCTION ❑ INO SFPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI*)( 1 HOW MANY 1 tJ Appno.eon 0 m s- '17- 7-c INSTALLATION WILL SERVE: RESIDENCFIET`�COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIORFASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT ❑ DISTANCE TO NEARIEST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING LINE ❑ NO.`LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BFD ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAOE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF TILE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:*I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHtCfI THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO W01 MAN'S COM TI LAWS OF CAUSO MA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGLARED INSPECTIONS. COMPLETE DRAWING BEL0 slo D x ATE: i C PLOT PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PnopOSFD 2. OVTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, FT,ON THE PROPERTY OR ADJOINING PROPERTY• 0 7 7— i •era• GI ...,..•..,,, '® .. 0 1 WILIIOIT-DOUGLASS TRA i • -" _..- eon »,a+a.+.�i,n .- aauu,., :. a.v n.o,..ee•wrr ..... „ar „y„M• MI . ' a� yr 8 .. h - q 3 1 F ¢ ...... ... I .: 9 . ea.int M .I nG> 1 .....: ........... ... .. PAY p� '••-"• WILIIOIT-DOUGLAS TRACT ' I .. ;a i' aceu�•Lao' aan.n 1 t : 98 1g PUfJUrJE)4(E/I(q GU 1YN C NEA T!i N1lIROFV/y $E IC£g _.:....... .........;......:............ . ENTAL_f it ql-ff i.DfVFtif4 n FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: AREA: TANK,PIT OR SUMP INSPECTION BY BATE / / FINAL INSPECTION BY DATE / J ADDITIONAL COMMENTS: _O ' r ACCOUNTING ONLY: AIDE FACN /KL� �1/tea 98' PE CODE FEE INFO AMOUNT RENTITTED HEC /CASH RECEIVED BY DATE SR/PERMIT NU1IMER INVOICE0 a