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?LICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .. ENVIRONMENTAL HEALTH DIVISION P,O, 13OX 388, 304 EAST VVEElER AVENUE, STOCKTON, CA 9.5201388 (209) 4883420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Tripliestel APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOW(DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1 1 10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# i-1) 1") )( I -a) 1{1\11.x\ t. L' J LOT SIZE 1 /!"Tr `' y, C• Y �iCITY (1..1..` t S OWNER'S NAME N.rl 1011 II�`�)�)I ADDRESS i�J 1.' 1I'-) VVAk),—U -)rC J� � � PHONE \ CONTRACTOR t.4)I.1�\I ''�I/\�trl.( a�' �, ji{I C., ADDRESS2,L� J`.)+�: IJ\E lI ((_�r{.... LICI PHONE�l1r11'- ` (�1 SIIB CONTRACTORI .� �_ I�a�.)1'aE )� ' �.) •I /l•i�1�1� ADDRESS i1C. I•J. V(-t� ,! ' .I'") ( ��14._ 11I' t i PHONE\.i-C UCM I'`C 1. II (.. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF 9UILDING.1 PFFIC TEST(.)1 1 HOW MANY I APdloenon # ; INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑_ NUMBER Of LIVING UNITS: NUMBER OF REDROOMS. NUMBER OF EMPLOYEES: rMAnACTER OF SOIL TO A DEPTH OF 9 FEET: PIT/SUMP SOIL.CHARACTER:_ WATER TABLE DEPTH SEPTIC TANK/GREASF TRAP ❑TYPE/MFO CAPACfrY_ NO.COMPARTMENT9 PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT CITATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LFACNNO UNE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNnFD ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE RT PAGE PITS ❑DEPTH SIZE NUMBER D19TANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREPY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RUI FS AND REGULATIONS Or THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE rOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUPCONTRACTINGSIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT 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 TIT I. i ,�/l!�t,/{,'[.(.(� DATE• C-•'1 — PLOT PLAN(DRAW TO SCALE)SCALE -ro 1. NAMF9 OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OI)TONE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. T. r IMENFIONFD OUTLINES AND LOCATION OF All FxISTNJR ANn rrnPOSrTTa .'O .AST r:1Ir rVRFP+, ;OCATiOf -1 LN-%,i RAORN3 DF O"E HJNDFFU rIF I Y FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. Ft I Y 1 WILIIOIT-OOUGLASS TRA;, 1 , ki ;•i _ SIL� ; a° \4 V- @i R w Mk .." l - -__-- - '" - `.r• ' WILWIT-IXIUGI.AS MAGI\ PAYMEN f• �• S �� " I - �*,~ ,.^�-;':,"'�:.. o SEP C 41998 P(IAIPOhOUIW l',v qVi r )8LI ,Ii--ALT - •- = nlvlslr�r.� j FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY (r ,L ;1-��/�•�--) \.�"\'✓ - DATE: fv , AREA:, 1 TANK, R U P Sr ECTION By DATE / / FINAL INS R'EC ION By DATE ADDITIONAL C M S: C/ , 3 ACCOUNTING ONLY: AID# FACT PE CODE FEE INro AMOUNT REMITTED 16HECKI/CASH RECEIVED BY DATE $A/PERMIT NUMBER INVOICE! 1 _� _ 1 1 I oo58S