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APPLICATION FOR LIQUID WASTE PERMIT 'SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (209) 4883420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW(DESCRIBED, THIS APPLICATION 18 MADE IN COMPUANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE..CHAPTER B-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNS ^ CITY �O �J LEON�SIZE,/y17)-4wC OWNER'S NAME �/`l/GFS- c/.z�C� ADDRESS �r ,, LLGtI�/ '/ �/ RHONE -tCR O Vim / CONTRACTOR ✓ •C1'7�/(/j'1. JC ADDRESS /-2/ UCI�7 YzZ 3 SUB CONTRACTOR ADDRESS UCE RHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUI ING.) PMC TESTI.)I I HOW MANY INSTALLATION WILL SERVE RESIDENCE Lf COMMERCIAL ❑ OTHER ❑ VA NUMBER OF UVINO UNITS:_L NUMBER OF SEWIG MS: 69 NUMBM OF EMPLOYEES: CHARACTER OF fi011 TO A DEPTH OF]FEET . cC RTISUMP SOIL CHARACTER '[k-IWATER TABLE DEPTH SEPTC TANK/GREASE TRAP ❑TYPERAFO CAPACITY T NO.COMPARTMENTS C PKO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEMI _ 3 Y LEACHING UNE NO.i LENGTH OF LINER /-4/0' �i yLP DISTANCE TO NEAREST:WELL-':S0, FOUNDATION �S H PROPERTY UNE FHLTM BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED (p❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION ROPERTV UNE SEEPAGE NR STLL TS 1y,sEPTH .�S / SIZE ¢ NUMBER DISTANCE TO NEAREST:WE -;�FOUNDATION PROPERTY UHE �S / SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 045MBAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND T T THE WOW(WILL BE DONE IN ACCORDANCE WFTH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THEBAN JOAQUIN COUNTY.HOMEOWNEROR I ENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING'ICERTIFYTHAT IN THE PERFORMANCE OF THE WOW.FORWHICH THIS PERMIT IS ISSUED ALL NO EMPLOY ANY PERSON IN SUCH/A ANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR eV CTINO ONA IFIES THE FOLLOWING: 'I CERT FY AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT ISISSUED,I SHALL EMPLOY PERSONS SUBJECT t0 W WLMAN'S OMPE ATI O ALIFORNIA.' THE APPUC NT M ST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWINO BELOW. SIGN % TITLE: �-f//ASV K/V(�j'/'j DATE: ^�Y PLOT RAN(DRAW TO SCALE)SCALE_'to 1. NAMES OF STREETS OR ROAD EAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WAMS. THE PROPERTY OR ADJOINING PROPERTY. �p %16 r<,.vILW J--3Ov 4 /OU• Ear A,. ee 1' SEP 25 1996 NOR.O MENTAL HEALTH ` PERMIT/SERVICES II FOR DEPARTMENT USE ONLY C?r APPLICATION ACCEPTED BV DATE: Z- AREA: p/"� .- TANK,PI JOA SUMP INSPECTION BY H DATE / �/ FINAL INSPECTION BV ATE ! l 11 ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDS .ACF PE CODE FEE INFO AMOUNT REMITTED HECK/CASH RECEIVED BY DATE Aft I PERMIT NUMBER INVOICE IF D s -1o aq s