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i� APPLICATION FOR LIQUID WASTE PERMIT 411 la,�t SAN JOAQUIN COUNTY PUBLIC HE' -H SERVICES V J .... ENVIRONMENTAL HEALTH ._,,SION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complltl IR Triplieatl) APPLICATION IB HEREBY MADE TO THE BAN JOADUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAGUW COUNTY DEVELOPMENT TITLE,CHAPTER9-1110.39-1J110.3 AND T/H/E STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DTVTSION- JOB ADDRRESSMFI API/ 7e gy f/ /h c'.iG /.I AL CITY LI�,I.-Wt�fi. LOT BRE _ OWNER'BNAME !AL3/ ADDRESS S�}UN'- PHONE CONTRACTOR l...A7n��/1�(G(/,i� iS�= ADDRESS �� L � U.- LIC/`YS7'90''/S PHONE 3,64—!;-0,97 SUB CONTRACTOR ADDRESS LICI PHONE TYPE DF SEPTIC WORK: NEW INSTAW ON❑ RERNR/ADDITION DESTRUCTION❑ IND SEPTIC SV6TEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) ►ERC TESTI.I I 1110-MANY �+, APPKwtlon! INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL❑ OTHER❑ NUMBER OF UVIN.UMTS: I NUMBER OF BEDROOMS:_NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF311 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTICSEC TANKUUREASEM [��, T P 4.TVPE/MFG e-') 6A1 CAPACITY NO.COMPARTMENTS W.TREATMENT PILNT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑El TYPE OF RUMP L SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING UNE El NO.B LENGTH OF LINES I- L4(-) L-Ln.FJI„"'-"C DISTANCE TO NEAREST:WELL GL' � FOUNDATION Ti✓' PROPERTY LME FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE Ne SEEPAGE TS 13 DEPTH_Y�SIZE S6 I1 NUMBER DISTANCE TO NEAREST:WELL ILC I FOUNDATION "IS` PROPERTY UNE fbO t own ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE (� DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION P OPERTY LINE 11 I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES �+ AND REGULATIO1,18 OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I 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. SIGNED X e, TITLE: Gc777A1l&a- DATE:&�/, PLOT PUN(DRAW TO SCALE)SCALE -Ia 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4.LOCATION OF HOUSE SEWAGE IN SAL 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 AREJLS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. �JL THE PROPERTY OR ADJOINING PROPERTY. __.__.. .. T' .... ....a.............a......;......,.............4............a. ....:......p......:......c............i....... ... < ....-.. ....... ..a......:......4.....�...... .........b....... ..i.....:............:......4........... ... ..... _ 4... ...o....-:......4......:......4...... ....4.....:......a......:.....o.... ......d......:......y. ..i. .b............o............' :: . . . . . . . . . . : ... ..... .� .. . .. 4.... �� J �.. 4......:...... .. o 0 i IM 7 <......:. ..<.. .... :............ . .. a G57i?N :.... ..yAlrk41UIM. 0. Cy ....... PUBLIG.?1EAli'.N,I��. ........o....;.. _ .,_ - _ :... . ...o.....,......3 FIpNMC-NTA - �O ........4.... ....a.....;......:. ................................b.... ......b............. .. .. .........o......_................_b............. a:............q......:. ...4......;.._..a......�.........._. ..... .. .. -. < FOR DEPAP.TMENT USE ONLY *4��, -- APPLICATION ACCEPTED BY DATE: ,L J� y'yFJ y/ q I AREA: TANK,FIT OR BUMP SISPECTIOII BY DATE / / FINAL INSPECTION BY AI �CG1/M'a'y DATE !�o 1 ADDITIONAL COMMENTS: AC COUNT..ONLY: AID/ FACE PE CODE FEEL 0 AMOUNT REMIITED CHEC CASH RECEIVED BY DATE SR I PBpMIT NUMBER INVOICE/ I, 0 /$�' �/PO.,m �a� Pub.HeaRh SERV.-Envlro.174(3196)