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APPLICATION FOR LIQUID WASTE PERMIT 3wW'JOAQUIN COUNTY PUBLIC HEALTH SERVICES'o ENVIRONMENTAL HEALTH DIVISION P.D. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 Al 1p (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Completo in Triplieets) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION/18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9A-11.10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# /Z�2 D///�/fV./��/i1/ ��,5 �/Rd A/ CITY AG- Av,IIJCJ LOT SIZE 10Iz9G OWNER'S NAME �ThDiJT O.S I(�f�//l��C ADDRESS Z5r--.201 /V / /�/L/I//eI .S, /`7 476ap _MONE 'J/ '1 'f 7 CONTRACTOR // IJ—C:f/\47Z� T.SG� ADDRESS✓e�Z 4 Y ZC1C�f�// �YCQ Ai ICI 12-�G// RION8, 67-61`/ SUBCONTRACTOR ADDRESS LIC# RHONE TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION TT DESTRUCTION ❑ +'� (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIFI�I/ImwL MANY APPII..SOR f Al C/'175 IJ INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ L (J NUMBER OF LIVING UNITS: NUMBER OF BEDROOM&: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PRUSUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS MG TREATMENT RANT❑ DISTANCE TO NEARFJT: WELL FOUNDATION PROPERTY UNE n LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) V' LEACHING LINE ❑ NO.B LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE C <_ NITER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE �+T SEEPAGE RTS ❑ DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,ANO RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE 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 OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 MALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT M U ST CALL K HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION{. COMPLETE DRAWING BELOW.` `r SIGNED X %' I /L-.�fT2 "'✓ TITLE: G-/j// / ��l+J�/Z��Y DATE: PLOT PIAN(DRAW TO BCALEI SCALE � 'tt 3D0/ 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PIIOPERTY. 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 Ol^ .Nn PROPOSED STRUCTURES, B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVET I .J5 95- /S N••n M I _ A: �wiwlf/VIw OYKe YV ItO, JEwttt eP. _ K�, EI 1JJla � � 1 rAwlcr EwER/rr/wvryeryt PARCEL / urunms a .vu</riw: mk wine: r....A• w!r C awwvJrrow: y� I e«cre/c/rY' v a c e. W /<aWwG .vAKNIIp.V M _ w _ __ neeo wr Joa¢Nss. /I sP/. sites a!w/i!wJ� .lce r vL, $ PARCEL JJ t "'UUU NVArecR a<ert'. e � •xsr EWA . ' F z W � W RE �` \j SEP