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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON.CA 95202 00 1 - O0 0 (209)468-3420 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICGIRpIBLB In NplkBLEI APPLICATION 18 HEREBY MADE TO THE SAN JDADUIN COU—-PERMIT TO CONSTRUCT AND/OR INSEAM.THE WOW(DESCRIBED.THIS AL`I'T(CATION IS MADE LN OOMPUANCE WIT11 BAN "AMIN COUNTY GEVELOPNIEM TITLE,CHAPTER 9.1110.3 AND THE STANDARDS OF SAN JOAOUIN CO-PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB AUDRE.F/DR APNF L<1 !2`-.l Clr+ n x� Lor BrzF iCi,t_ nwrreR B NAME 22v'uk InAig'-la 4 ADDRESS S PHONE DONT TDI't ri_.fi:,/ 2(.y�7r��i c- ADDRESS 41R LIC• PHONE?C: 5OZ7 6UB CONTRACTOR ADDRESS UCf PHONE TYPE OF REFTIC WORK: NEW INSTALLATION I& REPAIR/AOMTION Cl Dc.TRVCTT..❑ IND SEPTIC SYSTEM PLRMTTTED IF PUBLIC SEWER IS AVAILABLE WITLIIN 200 FEET OF 8111tDING.1 PFRC TFATI.I 1 I HOW MANY c�y9 APPHmtlon f INSTALLATION WILL SERVE: RESIDENCE KA COMMEFCIAL❑ OTHER❑ NUMBER OF UVING UNI78: I NUMBER OF BEDROOMB:�_RUMS.OF BAPLOYEEA: CHARACTER OF SOS TO A DEPTH DF 3 FEET: <A1r4',/ PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/EMEASE TRAF ❑TYPEMFO ' CAPACITY .gl'-- _NO.COMPARTMENTS MG TREATMENT PUNT❑ DISTANCE TO NFAREBT: WELL// FOUNDATION_ PROPERTY UNE UFT 6TATEON❑ 612E TYPE OF✓PUMJP�/� /SAND OIL /SEPARATOR IENCLOSED SYSTFMI y LEACHING UNE IS No.B LENGTH OF LINES — `/U,�V L•/'lfV�/P/YJCDIB TANCE TO NEAREST:WELL I SU FOUNDATION /6 PROPERTY VNE J u6 FILTER SED ❑WIDTH LENGTH DEF TN DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTN DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 6EEPAOE NTS ❑DEPTH 812E NUMBER DISTANCE TO NEAREST:WELL FOVNDATIOM PROFSITIV UNE SITUPS ❑WIDTN LENGTHDEFTII DISTANCE TO NF.ARE.T:WELL FOUNDATION PROPERTY UNE DISPOSAL FON08 ❑WIDTFI LENGTH DEPTH DISTANCE TO NEAFIE6T:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPAPEO THIS APPLICATION AND THAT THE WORK WILL BE GONE IN ACCORDANCE WALT BAN JOAQUIN COUNTY DRDINANCEB AND STATE LAWS,AND RULES AND F fGULATION8 OF THE BAN JOAW IN COUNTY.HOME OWNER OR LICENSED AGENT-8 SIONATURE CERTIFIES THE FOLLOWINQ:"I CERTIFY THAT IN THE PERFOIOAANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMM OY ANY PERSON M SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATIONLAWS OF CALIFORNIA.-LIFOORA."CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATUFIE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR VJHKN THIS Rwr,18198Uro,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS.COMMUTE DFAWING BELOW. TITLE: 1 � --DATE: SIGNED% PLOT PLAN 1ORAW TO SCAT E)SCALE_ Io 1. NAMES OF STREETS OR iIOAD9 NEAREST TO OR BOUNDING THE PROPERTYA. LOCATION OF HOUSE SEWAGE TXSPOGAL SYSTEM OR PROP06ED EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 2.OUTUNE OF THE PROPERTY.—.DIMENSIONS AND NORTH DIRECTION. 6.LOCATION OF MU-8 WITHIN RR/ ADB OF ONE HUNDREDFTY FIFT.ON 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EX16TING AND MOP06ED STRUCTURE e, THE PROPERTY OR ADJOINING PROPERTY. INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK6. (9111 J Q _ r.A PAYMFINT RECP-CVED I SEP l 9 2000 I : SANJOA(]UIN000NTY _l e'"-"' uw 0-p"- �0 C)01�� + I PUBLIC HEALIHSERVICES rC v�"�LJ 1 EN\ARONIA7,WA1HEALTHDIVISIO!I rw ?a FOR OEPANTM UBE ONLY DATE:1! 1 O� AREA: AWYIGATION ACCEPTED GV DATE / / FINAL INST'ECTION B116171�'� — DATE TRIM,NT Ofl SUMP INSI`ECTIOFI�BYV 1✓ G 0z) ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIOI FACS PE CODE TEE INFO AMOUNT POvRITCD CIIECKf ABI( RECEIVED 8Y DATE BK I PERMIT NUMHCR INVOICE f OD (,fllq P0 i Pub.Health So—-Enviro.174(3/96)