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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVIZ•ES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 W' (209) 488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICempleb in Triplicate) - -XPPLICATION IB HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS AP{YICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT/TITTLE,CHAPTER 9-11110.0 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 7 y JOB ADDREBB/OR AM# L L/T /7 � ' C`C9��/ r. /Cl/J Al/ CRV G - / 7-L�7 LOT SI7ZE OWNER'S NAME�IcA/� - h ee ^14,6`1 A,'ADDRESS ^t� PHONE �-S' / .327E I CONTRACTOR ` / /�. .��-J JG-�I ADDRESS -�Z`-G= ,' �/ � A.h1121 r.L1CS /,?-c / PHONE- BUB CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SETC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM KAMM ED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) FORD TESTNI 1 1 HOW MANY - APWIwnoA INSTALLATION WILL SERVE: RESIDENCE 13 COMMERCIAL 11OTHER ❑ NUMBER Of LIVINO UNITS: NUMSOR Of BEDROOMS: NUMBER OF W FLOYEFS: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PT/SUMP SOIL CHARACTER: WATER TABLE DEPTH N "PTC TANX/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS WO TREATMENT RANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE J UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) G LEACHING UNE ❑ NO.a LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH 812E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 0 SUMP{ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREBT:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PIIOPERTY UNE ` I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE MRN BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS Of THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PEAFORMANCE OF THE WORK FOR WNICH THIS RRMM IB ISSUED,I SHALL NOT EMPLOY ANY PERBON IN OUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR C SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE W01K FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOWMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE POR ALL REOMRED INPRTIONS. COMPLETE DRAWING BELOW. SIGNED% /�..-OC..-i "v-C'�Y" TITLE: rw_( DATE: s RAT PLAN RmAW TO BCALE)SCALE 'to 1. NAMES OF OTREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DIBFOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENGION8 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINED AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLU^ ^nnvcxn ARc.A AUCu PAUOA DRIVEWAYS,AND WALKS, r THE PROPERTY OR ADJOINING FACKAI^Y 01 N J WC w d Wd iu as V N / CL O cy- �vf M L�� a s 1 ' a s J iL F a~ F 04 RECE�lf PR 16 196 SAN JGAQU,,,CU,iN'PUBLIC HEALTH SERVICEs : G ENVIRONMENTAL HEALTH DIVI810 .DERE•.Y77r9c 0 J FOR DEPARTMENT WE ONLY 1 APRICATION ACCEPTED BY—S f�L). �1, DATE: I. t , AREA: TANK,PIT OR SUMP INSPECTION BY DATE / / FINNAL�,INSPECTION BY / J�.� � A ADDITIONAL COMMENTS- / 1461 l 'I U-U' q 1 / ACCOUNTING ONLY: AIDS FAC* PE CODE FEE INFO AMOUNT REMITTED eCHfCK#kA&H RECEIVED BY DATE M/PIPIN T NIANBEIL INVOICE 0 73i R