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APPLICATION FOR LIQUID WASTE PERMIT s n4'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9.5201388 (209) 488-3420 /� NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED / 1 PCOMPqUYEWTT"SAN(CRmplsto In TTipiksts) 1`.//AMICATION IS HERFBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS A ION DE JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER (�9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH S'ETR-V�IC1E`S,cENNVIIRONMENTAL HEALTH DIVISION. �7 JOB ADDRESS/OR APNA �� ly7�y^ �� 1 \�] ►r i2. 2(J Aso\) w 11 lUk„ut m Cr'Y _S 1 VI�L�-1�y`�r LOT SIZE `' 711P OWNER'S NAME'��l`��`�"� ^ 1' `V�S� ADDRESS J�YjO w. M\)U.1j, � `a'Ut O PHONE ZG�1 \\ CONTRACTOR •\Ir VIc��int�-ULL �' ��)njQ�.^ ADDRESS %O ':LU f� W k• ( Q LACAC, LICI �7 PHONE(•ZC+T11 Z3C1 IIOa� SUB CONTRACTOR_N Li1L U. Amtit..R-boo) Am, &13ry DoRESs ZZ k k� . l - / uC/ \L.w 4y I PHONA2LIC1 36 ) 3`�bl TYPE OF SEPTIC WORK NEW INSTALLAnopt jl--- REPAIPJADDITION ❑ DEST14UCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDING.) PLERC TESTIal I 1^N(OW MANY -7 INSTALLATION WILL SERVE: RESIDENCfi'❑/COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF SEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFO CAPACITY 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 D19TANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER REO ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE LL SEEPAGE MTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WF UL_ PROPERTY UNE SUMPS ❑MOTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE THEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A9 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR-9 HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SURJECT TO WORKMAN'S COMPENSATION LAWS OF__�LIFORNIA.- THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. ii SIGNED X—"! cl r __ ?,� i �Q`` /n�.. �7 • TITLE! s�Tl/ � IV Grn, > >\l �O AAs DATE: C. PLOT PIAN(DRAW TO SCALE)SCALE -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF"OUSE E DISPOSAL DISPOSAL SYSTEM OR PROPOSED 3- DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, EXPANSION F SEWAGE THIN SAL S OF O9. INCLUDING COVERED AREAS SUCH AS PATIOS,DFUVEWAYS,AND WALKS. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Ff.ON .__ THE PROPERTY OR ADJOINING PROPERTY. W, ! WIL HOI7-%OUGLASS TM" PAT FBftEV it OCT 0.51998 v, ,S s`•4i7 ILLI%+i)pIM UL g.bV l l L.ALTh} L ! r i p 3 _._ ¢ b '�INM�NTAL I-IF _AQI4 O!VIS!��I i ......;.............;. _. .`........... 'Z i ..... '. n ,.. 'P t waHolr-oaTclns TRACT .. .....-E.....;... ni I ., ,,� a•u i.1o• » ,/ EPARTMENT USE ONLY APPLICATION ACCEPTED BY �v`' "� /` - DATE: V AREA: G- I TANK,MT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BV I^ n •' - DATE J ADDITIONAL COMMENTS: Cti -� V�C�CYI - eA-o- , — f W 1fiiCL�SSED �,9Sr / /Ir ACCOUNTING ONLY: AID/ FACT PE CODE FEE INFO AMOUNT REMITTED CHECK/)CASH RECEIVEDBY DATE SR/PERMIT NUMBER INVOICE I U