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APPLICA- "OR LIQUID WASTE PERMIT SAWJOAQUIN�JNTY PUBLIC HEALTH SERVICES • ENVIRONMENTAL HEALTH DIVISION P.O.BOX 38B, 445 N. SAN JOAQUIN ST., STOCKTON,CA 952010388 (209) 4683420 —. RON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN 40UIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Q� )ADDRESS/OR APP, ^A��(3 O ' I �I LCL�`IL I '1 q CITY C � )1 11 ' LOT SIZE _( I L'( f 1 Mn 2 �1 OWNER'S NAME �1 ql 1 c l� I� ADDRESS {�J�/Q('I-1�-/U�� 1/�L( ( l PHONE -)/�Q�' __NTRACTOfl /1 `' � � ADDRESS')(V�-I e�I V\ 1 ��VLJ Jl LIC, G- PHONE�1(1 L -Z�9:35 3 CONTRACTOR ADDRESS LIC, PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION❑ ;NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.I I 1 HOW MANY APdicetlon IFTALLATION WILL SERVE: RESIDENCE COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITS:_L NUMBER OF BEDROOMS:_NUMBER OF EMPLOYEES: ri CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/PUMP SOIL CHARACTER. (�. WATER TABLE DEPTH (TIC TANK/GREASE TRAP 10 TYPE/MFG CAPACITY NO.COMPARTMENTS 3 TREATMENT PLANT C1DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OFPWPSAND OIL SEPARATOR(ENCLOSED SYSTEM) ^ LEACHING UNE )4 NO.a LENGTH OF LINES ")_ Y —/0' DISTANCE TO NEAREST:WELL (=FOUNDATION�O PROPERTY LINE_ TEA BED 13 WIDTH LENGTH—� DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION_PROPERTY LINE --PAGE PITS �.7 �II-- �DISTANCE TO NEAREST: �— W NUMBER WELL=FOUNDATION PROPERTY LINE Iq DEPTH 512E SUMPS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE nI CPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE V` =REBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES —DREGULATIONS OF THE SAN JOAGUIN COUNTY.HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO O RKMAN'S COMPENSATION LAWSOFCAUFORNIAA..',T,HEE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION&&. COMPLETE DRAWING BELOW. _NEDX Ob _-1 uLX ale t(V L.1 l C, %'--+'C.�TITLE: bLcnt k- �� l DATE:F )o C J PLOT IN(DRAW TO SCALE)SCALE 'to ' NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, IV 9 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON ^ INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. 1 THE PROPERTY OR ADJOINING PROPERTY. jl LO .0 �u Lu .............. qF s"REIJ MAY 3AN.IQAC�uIN GQUN Ya �Ual IC HEALTH SEFIV.,IC.E,S:-- S q'::'MF%TAL HEALTH pIvISJ.QN FOR DEPARTMENT USE ONLY I 9 PLICATION ACCEPTED BY JAI DATE: AF 6 OR SUMP INSPECTION BY DATE/ 0/ FINAL INSPECTION BV `-T DATE Q/ S 01TIONAL COMMENTS: ACCOUNTING ONLY: AID, FAC, PECODE FEE INFO AMOUNT RENIITTF HEC /CASH RECEIVED BY I DATE an l PERMIT NUMBER INVOICE, a � 1' :l - � f 671,SP 7q