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` iAPPLICATION FOR LIQUID WASTE PERMIT N'JOAQUIN COUNTY PUBLIC HEALTH SERVICto ENVIRONMENTAL HEALTH DIVISION f P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKMN, CA SMI-388 12091460-3420 NUN-REFUNDABLE PERMIT EXPIRES 1 TEAR FROM DATE ISSUED (Comptek in Triplkmtn► APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# 1 _ C r n i� LOT SIZE OWNER'S NAME f�tC' L' (V-v ADDRE88 (�rad PHONE �j CONTRACTOR_1'f` 1 _L K.I'� ,,.. ADDRESS 't'l..(rad 1 UC♦ I 11Cy PHONE s ac?-ga�I OUR CONTRACTOR ADDRESS UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDIT16N DESTRUCTION INO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.] PERC TEST(s]I I NOW MANY .may Appil"don 0 INSTALLATION WILLSERVE: RESIDENCE12 COMMERCIAL❑ OTHER ❑ NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF BOIL TO A DEPTH OF 3 FEET; PfTJSUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASE TRAP ❑TYPE/MFG CAPACITY NO,COMPARTMENTS PKG TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL - FOUNDATION PROPERTY UNE UFT STATION 0 SIZE TYPE OF PUMP SAND OIL SEPARATOR{ENCLOSED SYSTEM) LEACHING LINE C NO.•LENGTH OF UNES ` DISTANCE TO NEAREST:WELL -" • FOUNDATION PROPERTY LINE r. FILTER BED D MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH 812E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS X WIDTH �'—LENGTH iO' DEF'T141: `r OWTANCE TO NEAREST:WELL—LA�� .FOUNOAT{ON F'ROPERIY LINE DISPOSAL PONOS ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOU1N COUNTY ORDINANCES AND STATE LAWS,AND RULE; AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'e SIGNATURE CERTIFIER THE FOLLOWING:"I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 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 SU13-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LA OF CALIFORNIA' THE A ANY MUST CALL 24 HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW 1 �['� r' I SIGNED X TITLE: I o I 1, T�DATE: I `/ j 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 PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMB. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ✓ THE PROPERTY OR ADJOINING PROPERTY. .,_.,. ---...;.,. .;....,-f ..... .... ..... 71 .. .,.. _ _ ., ...r.. `�, .. . - .. v .. . .. r � rt�?�!llv.ccxaNT.y : - - r ENVROfJMENTAL HEALTH DEJISION .. - IJP - '. - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY / y� DATE; AREA:_ L �_ TANK,PIT OR BUMP INSPECTION BY DATED IW .'FINAL INSPECTION ` DATES:& ADDITIONAL COMMENTS: - ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED NECCICASH [RECEIVED BY DATE SR I PERMIT NUMBER INVOICE# �f2fD Sells 1�' oa � S