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'PLICATION FOR LIQUID WASTE PERMIT SA 'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ..r ENVIRONMENTAL HEALTH DIVISION RO, BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (2091468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplk*te) AP'UCATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TIT CHAPTER 9-1`1`10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOR ADDRESS/On APN# S 1 1� ( I� �/ p 1 �7 a CITY V L Df- 2 LOT SIZE f�RGS OWNFR'S NAMF MB f NR/)T� V'ft ji 1,.�Ie�iv- ADDRESS 11 1 W A,�(�R�£'e{'VRT 7 2 PHONE CONTRACTOR M00O t,(/ � SI F" �.JC�CG� ADDRFSS gbLj,; �Z LIPWrL-, L•4`0- LIC# 73Z/7C1 l PHONE q3l-V+qj SUR CONTRACTOR ADDRESS`•)-ryw' CA •��1 Z" LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION, DESTRUCTION ❑ IND SEPTIC SYSTEM I`ERMTTT ED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEFT OF Bl11LDIN PERC TESTW I 1 NOW MANY M _1R �kJI S Applloatlon# INSTALLATION WILL SERVE: RFSIDFNCF❑ COMMERCIAL J� OTHER ❑ ((i.' 1 V4-1� I ,;(-I V' NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOM*: NUMBER OF EMPLOYEES: ! 1( CHARACTFR OF SOLI.TO A DEPTH OF FEET: 1-O R W\. p-, LPEE/SUMP l SOIL CHARACTER: WATER TABLE DEPT14 K/ SEPTIC TANnRFASF. TRAP @y TVPF/MrG NC'N•��1�'� 1' IL � CAPACITY I,�00 CI Ok IIDN NO.COMPARTMENTS (✓ PKO TREATMENT PLANT 11DISTANCE TO NEAREST: WELL '150 e4 FOUNDATION S / PROPERTY LINE C� UFT STATION❑ S17F TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.S LENOTII OF LINES DISTANCE TO NEAREST:WFLL FOUNDATION PROPERTY LINE FILTER BED WIDTH LENGTH DEPTH E L DISTANCE TO NEAREST:WELL /�Z'•� FOUNDATION > ' PROPERTY UNE Z-'" MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS API ICATION 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 CEFTTtF'YTHAT IN THE PERFORMANCE OF T11E WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY APIY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIRING OR SURCONTRACTINGSIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFIK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* THE APPUCANT MUST CALL 24 HOUR*IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. �} SIGNED X ►"`� J �T TITLE 1 DATE: CACI 1��' C• C r�N iRPcTI T POT PLAN(DRAW TO SCALE)SCALE 1. NAMES OF STREFTS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. !Yf L'i•LL' 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 14 Nv EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXIS71NO AND PROPOSED STRUCTU S. 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 I I AXI 5•S INc'�. /V/C If •r/1 �x`►SstNcr I I I[E1.1Nt LS r P 4. 1�ay4 0 0 <� r_ r LF—=rye Q Sr�-Q-cf,.gu•r coq FOR DEPARTMENT USE ONLY y J,. APPLICATION ACCEPTED BY ` V (,I (�+ '�(.L�' �` DATE:_ ( l LI C/ \ AREA: r ' TANK.PT On RUMP INSPECTION BY /I f DATE / / FI NAL INSPECIION BY DATE64 ! L— ADDITIONAL COMMFNTS:/ ( (• l l L C�.0-L'l,f 1� t J I'�(,� 7 '/)i /,! ` / �•�'� ( - (,I l I (/': / ' '' -ilr-1 . _. _ � (I l ( LI" l"R l 1. I ,;i( �l c• r l� ---- _ - ACCOUNTING ONLY,TING ONLY: AlU#�(AC# PE CODE FEE INFO AMOUNT REMITTED CHEC (CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE f ,