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a �ePLICATION FOR LIQUID WASTE PERMIT JOAIIUIN COUNTY PUBLIC HEALTH SERVICE i ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9M`I-88 12091468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cemplate In Triplieatal APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED, THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS Of SAN JOAQUIN COUNTY PUBLIC HEALTH BERVICES,E VIRONMENTAL HEALTH DIVISION- 7 (v S Sµ ++��// 77 - JOB ADDRESSIOR APN-/ s_ s.�Jd/CL7f'jjf�( U I"^ _ __c CITY ` LOT SIZE � J i OWNER'S NAME L `�//L L/(�� G7% ADDRESS `� y4 lJ 1 V_� PtIONE _ CONTRACTOR IG b�• ��flJ�F2s4+�? ADDREBSG �(Juy I '.0 Z.&/ _LICOC;- PHONE�(e.'7" 3 711 SUB CONTRACTOR ADDRESS LIC# PHONE I TYPE OF SEPTIC WORK! NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ ..��JJ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.! P6IC TFATIO'KNOW MANY 7 (r INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BRAROOM8: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIGRFASE TRAP ❑TYP£/MFD CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINET? Lit LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR!ENCLOSED SYSTEM LFACHING UNE ❑ NO,A LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE _.RLTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE r MOUNDED ❑W OTMI LENGTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ,. SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDAT43N PROPERTY LINE Bumps ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH RAN JOAQUIN COUNTY ORDINANCES AND 11TATE 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 WIIICH 7141B PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENBATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWIN ."I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN' TION LAWS OF CALIFORNIA.' E APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS. LE COMPUTE DRAWING BELOW. SIGNED X ��- ,/•^ TITLE��/ (,7/�, !/`�C+/� DATE: G.� / y PLOT PLAN IDRAW TO SCALEI 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 OP ALL EXISTING AND PROPOSED STRUCTURES, 6. 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 fc�EL-I" "Of51CH.4TFO RCI.wNDEi' I Q IG 'Ilk 'Il L e {I ^ I I wom ne em ee - i A 0 1997 ,l�...r . ....... ..... -.. ',......... • !, ..u., I NuS� (IHS U 1 - hl 1 � I� � �C' = S 'U' } • � Jyt tl L eea•asr0»eon 1 b � . _ SOUTHLANO AVENUE !r FOR DEPARTMENT USE ONLY _- - APPLICATION ACCEPTED BY -\CDATE: AREA:— j .._` l /� I ANK,PIT OR SUMP INSPECTION BY / DATE I ! FINAL INSPECTION BY 1 �.i"V 1� 1'V`Ll �C- DATE id ' ADDITIONAL COMMENTS: ? fY7 -�.1-- r-/-_).-'.-c•-�'� {. ACCOUNTING ONLY: AID! FACT PE COOS FEE INFO AMOUNT REMITTED CifFCK_#?CAS l RECEIVED BY DATE BR I PERMIT NUM8M INVOICE R