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APPLICATION FOR LIQUID WASTE PERMIT 1 .e !sAN'JOACIUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 971 6�, P.O. BOX 388,304 EAST WEBER AVENUE,STOCKTON, CA SMIX88 ` (209) 468.3420 J NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUE ICampl.te In Tripliantel APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9�-111 1 O,3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,`�ENVIRONMENTAL 14EALTH DIVISION. ADDRESS/OR APA# IT I[� . /�/ltll,ni�'c� /G. _ _CY4THSCt��M. •_— J ��y—LOT SIZE ' ` OWNER'S NAME��\I��d�jll Z.4ln/�/�, ADDRESS �i�i�` �•_1�u /,, C� PHONE_ p► 5� / CONTRACTOR/[J�/L 6 /`�4.><� o+V V !+�V O C—ADDRESf r7(�U/7G/tJ ZA/. 1' Lh I . --- L PHONE367 370 I SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEATIol 114O/W�MANY Y ApPSoodon INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER 0 NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP BOIL CHARACTER: WATER TABLE DEPTH r SEPTIC TANKMREASE TRAP ❑TYPEIMFO CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ INSTANCE TO NEAREST: WELLFOUNDATION PROPERTY LINE LIFT STATION❑ 8i2E TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED BY87EMI C) LEACHING LINE ❑ NO,h LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE l!\ MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE V ) SEEPAGE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 771, SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE /^ DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE \� 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AHO RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIEB THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PER8ONSI SUBJECT WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLI T MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPPEEC`TIIOONS, COMPLETE DRAWING BELOW, SIGNED X 1 — TITkE��/f✓/ G -_— —DATE:4z/ J PLOT PLAN(DRAW TO SCALE)SCALE 'to i, NAMES OF STREETS OR ROADS NEAREST 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 OUTLINER AND LOCATION OF.ALL EXISTING AND PROPOSED STRUCTURES, B, LOCATION OF WELLS WITHIN RADIUB OF ONE HUNDRED FIFTY FT,ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ...` ',......._, ` ... ... ................. Ir .'... v K .... .. ........'..,..,.... :'.: z♦ ...we. Lia ' �„�,•,,,,�� .., I \• I \ / f � 1l-e-N 5 I T F P L L�-.L lnaa ,kms .. ..... , .. .;..... ....:..... � IVL T e" Y 11Gr ly - L. •: i � 1997 a o I. ! ENV NSC Eq� ouwy AtO FOR DEPARTMENT USE ONLY +� APPLICATION ACCEPTED BY DATE: TANK,PIT OR SUMP INSPECTION BY DATE 1 FINAL INSPECTION BY DATE- `] r 7 ,� ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAG# P£CODE FEE INFO AMOUNT REMITTEi1 C ECICASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE#