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APPLICATION FOR LIQUID WASTE PERMIT AN'JOAOUIN COUNTY PUBLIC HEALTH SERVIC6rs ENVIRONMENTAL HEALTH DIVISION RO, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 488.3420 i - NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comp ete In Triplicate) APPLICATION 18 HERESY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/on INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WRH S JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110,3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HAN 'I LHEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# 11JU %l T, /, p/) CFIY-- ' �A/ r� LOT SIZER� S OWNER'S NAME_ /S /m /;�y y 4n�:-,�` ADDRESS �R 7410 fL /', //tel �l� PHONE CONTRACTOR_ ADDRESS CD � �) 'f/y - ADDRESS SVB CONTRACTOR _L 1 yl/915 ADDRESS LIC# PHONE If _ LIC#-!! �jAx5 PHONE � TYPE OF SFPTIC WORK: NEW INSTALLATION 14 REPAIMADDITION ❑ [)EST-RUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEINER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PMC TEST()I 1 HOW MANY INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL 0 OTHER ❑ �///�/�y>1/I/ti�![� � •vq APdlo.6— IF NUMBER OF LIVING UNITS: NUMREi OF,�B"EDRO/OMS: NUMBER OF EMPLOYEES: �5 CHARACTER OF SOIL TO A DEPTH OF 3 FEET: V/V(! PIT/SUMP SOIL CHARACTER: " WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ps-41PE/MFO_ I�rJc! �j.f CAPACITY 2)NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO HEARE6T: WELL FOUNDATION PROPERTY LINE UFT STATION❑I-SIZE TYPE OF PUMP SAND OIL SFPARATOR(ENCLOSED SYSTEM) LEACHING UNE W NO.Si LENGTH OF LINES .3 k;i DISTANCE TO NEAREST:WELL G7DO FOUNDATION /CIO/��PROPCRTY LINE /,:0 FILTER RFD ❑WIDTH LENGIN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTN SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DIRTA14CE TO NEAREST:WELL FOUNDATION PROPERTY UNE 1 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:"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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. i J SIGNED X z7'1 -- TITLE: CCiti7`//'+�/�'</ —DATE:- PLOT PLAN(DRAW TO SCALE)SCALE •ro 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,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. F74 p/ t lex 8dYZ: C�9ch X oc T ofd A _ . 17 60 �`.ter.... I (� . FC IVB- JE1(d 2 4 1998 CUL i F _ .. SAN JQAULIIN pUBL1C HEALTH.SEFt 9C G NVIROr1MENTALHFALTH FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: AREA: n TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE / ADDITIONAL COMMENTS: 1 e ACCOUNTING ONLY: AIDF FAC# PE CODE FEE INFO AMOUNT REMITTED /IE KI A6H RECEIVED BY DATE 6i1/PERMIT NUMBER INVOICE z ams