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'PLICATION FOR LIQUID WASTE PERMIT SAh-JAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-M (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED c (opy (Complete in Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 2 JOB ADDRESS/OR APN#yam,X��Q r7 C9,k V�� Z� ^� CITY -\0(�. LOT SIZE JCI. O ACQ OWNER'S NAME �-.!1/\ 1..�I L�.y� �7L'�A (� � ADDRESS J'� 1�� E. T 1'Z.�rJ�2 PHONE 'y-� `y, CONTRACTOR AN%i AP tL� 17 -5 r G N l71\LCWC ?ADDRF6S ��-7��L7I� A^S Z�1 t( S� '` UCI PTIONE J ' 1 ' 101` SUBCONTRACTOR�J�It- O, Ah1L�R� '11RSSA(ADDRESSr�US�b AJ LM ujt� 446X�. pHONE3(o`1 -3101 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADMTION ❑ DEGTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PFIRC TESTW 1 I NOW MANY__ APpIiosSon INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCl/rr� OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYM: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PTT/SUMP BOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP [ITYPEIMFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) IFACNNO UNE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE _ FILTER RED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE _ MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH 812E NUMBER DISTANCE TO NEAREST:WILL- FOUNDATION PROPERTY LINT SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY 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 SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH T1418 PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION).AWB OF CAUfORNIA.' TILE APPLICANT MUST CALL 24 HOURS IN ADVANCE F011 ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED f( Lila / TITLE: O)ONL4( 2 DATE: PLOT PUN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF 140USE SEWAGE DISPOSAL SYSTEM OR PFOP06E0 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, R. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. i • I� - i s£C H r2s FBE v 1 _ AUG.26 1998 � o _. ... M Ke •.....•... wn e. taD-ne zz A14,tUiU.;UIN:C.Gt;N fl . PU6LJC,H'EAI_Tli:SEFNICES ENVIRONMENTAL HFAi_TH DIVIS:(?- F�R!-�DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- r L /� �"f'� DATE: -:2— AREA: TANK,TMT OR SUMP INSPECTION BY 9-D'A'TE / FINAL INSPECTION BY L DATE ADDITIONAL COMMENTS: � T11 r all ,�` 11 i I\ ? I 1� iii ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED HEC #/CASH RECEIVED BY DATE SR/POWIT NUMBER INVOICE 9