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APPLICATION FOR LIQUID W, PERMIT ..- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 (209) 4693420 NONREFUNDABLE PERMIT EXPIRES L YEAR FROM DATE ISSUED (ComplJb in TriplicEtJ( APPLICATION I9 HEREBY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED, THIS APPUCATION 16 MADE IN COMPLIANCE WRH SAN JOAOVIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 ANO THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR AP'NI -"' Z� CIiV ��"/J�1•[/j J LOT 612E�_ OWNER'S NAME /',fj, .iI L / l71C� tl:1ilRC / / ADDRESS PHONE��,J�-_L�� CONTRACTOR ` ;JI� `,/�.e�' TA/ii ADDRESS Jfl'�C� > , / �j� UCJ �y,JY� RIONE- y-G-dz,J SUR CONTRACTOR ADDRESS cL-a� UCJ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION W DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING) PERC TESTI.I 1 1 HOW MANY AoWloatlon J INSTALLATION WILL SERVE: RESIDENCE 19 COMMERCIAL Cl OTHER❑ NUMBER OF WINO UNITS: NUMBER OF BEDROOMS:_NUMBER OF EMPLOYE": CHARACTER OF SOIL TO A DEPTH OF 3 FEET:FTt/SV/MP SOIL CHARACTER: WATER TABLE DEPTH ) SEPTIC TANK/GRFASE TRAP ❑TYm/mrG. ��w> - CAPACT' 49122 NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTI'LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SVBTEMI LEACHING UNE GI' NO.S LENGTH OF LINES F,•AA)' DISTANCE TO NEAREST:WELL IDB' FOUNDATIONS_PROPERTY UNE %5 RLTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE FITS DEPTHa�;-, g6_SIZE � " NVMBER_? /�S DISTANCE TO NEAREST:WELL_ FOUNDATION 'I.MIPROPERTY LINE 1,71 � SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE L- DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WTTH BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAGUIN COUNTY.HOME OWNER OR LICENSED AGENT'S BIG NATURE CERTIFIES THE FOLLOWINO:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO SEC GME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'i CERTIFY THAT IN THE PERFORMANCE OF THE WOW,FOR WHICH THIS PERMrT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOPKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED%j!_i�yTITLE: /UDATE: /C PLOT PLAN(DRAW TO SCALE)SCALE-- 1. CALE "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,WRH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OVALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELL8 WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ... _ ....... 1-1a�s� �. ......... J �C 1 O q�f ..... PAYM yyyy�i { EN p� y 3�xas' ntav 1 �9 UBLTC HEAL TH°Er1 fl ta' �VIP7IJMENTAL I�CA!.TI DP' FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BV T DATE: //J J LJ�� ARFAZ� 2 C AN ,SI I/OR SUMP INSPECTION BV / DATE//_L/7�51 Al INSPECTION BV'�,.QJ�f'/�,r-u/C{�(�DATE ADDITIONAL COMMENTS: - ACCOUNTING ONLY: AID' FACT PE CODE FET'''^^k AMOUNT REMITTED CHECK/ ASH RECEIVED BY DATE 8A/PEFWIIT NUMBER INVOICE J oa