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I APPLICATION FOR LIQUI13 WASTE PERMIT SAN-JOAOUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRONMENTAL HEALTH DIVISION RO, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA MMII-388 �� (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE (Complete in Tripllcattn) COPY APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANb /OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAH JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. i4�tq�. � ,c:A.Sr33Za 'i'AkX. #+ - .� JOB ADDRESSJOR API/S t' CRY �' L_n 812E AC OWNER'S NAMEADDRESShi 1_" - C� PHONE. [ COWRACTOA 1 ADDRESS /�L-at]JS24'L ICI PION .'...� OUR CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION ❑ DESTRUCTION ❑ - (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) )1�ftRC-OLATLOt4 PER TESTTvI I I HOW MANY___ TerST AppRoe@en! 7 -- Q -- INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ HUMBER of LIVING UNITS: NUMBER OP BEDROOMS: NUMBER OF EMPLOYEES; CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION 11SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.A,LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WfLL FOUNDATION PROPERTY LINE MOUNDED ❑W OTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BUMPS ❑WIOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY-HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TH£FOLLOWING;'I CERTIFYTHAT 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 DR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTLONS. COMPLETE DRAWING BELOW. SIGNED TITLE:CIYtL EL-1r_iy, PLOT PLAN(DRAW TO SCALE)SCALE 'to 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, 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 8. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,EnVEWAyB,AND WALKS, THE PROPERLY DR ADJOINING PROPERTY, . 77— .. bPA'macg I n.�� '3 rapPM ZjAy 9i � �Jisr .t .3.�a - /kc_�s4�L .. DRiu>cvwq INS.bAILR .. #vtAi� ' --�_. b 9 AYMENT sK RECER F.SEP. 199 /lkE SAN JOAQUI COUNTY .......-....:.......:.............f......:.......L......;......i...... ..... i' .HEALTH DIVISION FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY c DATE: AREA: TANK,PIT OR SUMP INSPECTION BY v DATE I / FINAL INSPECTION BY C., /� �_ / F777777 DATE / ADDITIONAL COMMENT at ACCOVNTINO ONLY: AIDS FAC,► `K. .,PC CODE FEE INFO AMOUNT REMITTED CHECKI/CABH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE I '� 0 3 �`�Iay�5 t