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y : APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 I EI (209)468-3420 �e J r f LJy g OWNEFUNUABLE PERMFT EXPIRES I YEAR FROM DATE ISSUED U �{ S /O q&7 A ! Y-�- q7-&- lCompIBD1 In TFIPSN(B) ' APPLICATION to HERESY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COM PNCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 80-I F 1110.9 AND THE STANDARDS OF: JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. Job AOORESSAaR APN<' QS '� TO" / ry�,y ( £i CITY, LOT BRE OWNER'S NAME �1N C f ADDRESS r I�-N� F P-P 9 7-1_ CONTRACTOR VA LLA U /`t� 1'C F-5 Gh'��A ADDRESSP12 1TUR—LOC-le SUB CONTRACTOR ADDRESS LIC/ Pi1Dt4£ TYPE OF SEPTIC WORK: NEW IN&1 ALLLTION ❑ REPMFUADOITION ❑ DFArRUCTION ❑ f IND SEPTIC BYSTN'M PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Appm doom 0)E 1 HOW MANY 1 INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOM&: NUMBER OF EMPLOYEES; CHARACTER OF SOIL TO A DEPTH OF 3 FEEL: PTISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASE TRAP ❑ra'F-dFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR IENCLOSEO SYSTEM) LEACHING UNE ❑ NO.a LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BW ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WEtl, FOUNDATION PROPERTY LINE MOUNDED13WTOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL. FOUNDATION PROPERFY UNE— SUMPS NESIRUPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL POUNOATION PROPERTY UNE v DISPOSAL PONDS ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELLFOUNDATRIH PROPERTY LINE I HERESY CERTIFY THAT I 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 SIONATURE CERTIFIES THE FOLLOWING:'ICERTIFY THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOf4NA.- CONTRACTOR'S HIRING OR SUS-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOPKMAN'S CMN LAWS AIJFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SHINED X "LL�. TrTLE:,. (f/WIN�1 L- _DATE' 3 . 1 •.�/ T PLAN(DRAW TO SCALE)SCALE -le I. NAMES OF STREETS OR ROADS NEAREST TO OR SO OINQ 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 WALKS. THE PROPERTY OR ADJOR04G PROPERTY' r ... - .. _ .. n� �l l -- - .. .... .. _ ..- - -- .. .. __ .. ;. . ..... j .. ............ ..... ' .. .... . . . ....... ................................ .. . .. .. .. . ............ ...... .................. Q�.'.1. ...... _..... ......,