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APPLICATION FOR LIQUID WASTE PERMIT ..N'JOAQUIN COUNTY PUBLIC HEALTH SERVICL ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4083420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 'PLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 1S MADE IN COMMIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER)9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OPE APN# r2�41 Z, � q+/V I ,� VJL,/�S 0D. /J[] '( j�� Com` CITY ACAMPU LOT SIZE /�I OWNER'S NAME�AY-I U�/ y; 'PeA LLL 51L VA ADDRESS 2(- 1 1 Z�I 1\1 W wL65 �j2. [J PHONE 366 I 30 CONTRACTOR D/LUCIA C' M �kP(. Y ADDRESS i6:?C) W iC6TTi--FMf�N aLIC# ZSC':5S PHONE 7rJq-GVI3 SUBCONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Z IND SEPTIC SYSTEM PERMITTED IF PUSLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.( PERC TESTNI 1 I HOW MANY ✓ APp1PeBPn IF M 5— !� �}'ry 7 INSTALLATION WILL SERVE: RESIDENCE 11COMMERCIAL ElOTHER ❑ NUMBER OF LIVING UNITE: NUMBER OF BEDROOMS: NUMBER OF SYMOYEES CHARACTER OF SOIL TO A DEPTH OF 3 FEET: RT/SUMP SOIL CHARACTER: WATER TABLE DEPTH \('` SEPTIC TANKIOREASE TRAP ❑TYPEMFG CAPACITY NO.COMPARTMENTS T• PXG TREATMENT PLANT❑ DISTANCE TO NEAPEJIT: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF NMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) 1 LEACHING UNE 13 NO,i LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I j FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY'LINE T1 MOUNDED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PIROPERTV LINE SEEPAGE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE Z SUMPS 11 MDT" LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE //� I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES j1 AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CEWIPYTHAT IN THE PERFORMANCE OF THE WOR(FOR WHICH LJ 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 C SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO c WOWMAN'S CCOMPPENSATION LAWS OFF CALIFORNIA.- THE APRJCANT MUST CALL N HOURS IN ADVANCE FOR ALL REQ'UIR'ED/INSPECTIONS. COMMETEE DRAWING BELOW./ (�/ SIGNED X " Ili)� Cry l..l l:�'^' 1 TITLE:J F- I- ( YF I L t7/u JlJ F4-1 DATE: � - i5'- ( `�o ROT PLAN IDRAW TO SCALE)SCALE 'N, 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, S. 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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.O INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. GGLL_102 7-0 40 PAYMENT Pj Ca- RECEMIED NweJ pyo ,Pa��F AUG 15 1997 Ila � i= � , 3 Z09 SAN .` JO GSE } Uf3LiO HEALTH RV(CE S SAuJ cNlIHOOMFNTAL HEALTH DIMS IOP. 5T Ab ES I ytspllc. � L-I:AL..N AKEA II III -House II