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APPLIr IN FOR LIQUID WASTE PERMIT SAN JOAL :OUNTY PUBLIC HEALTH SERVICES ENVITIONMENTAL HEALTH DIVISION P.O.BOX 388,446 N. SAN JOAQUIN ST., STOCKTON,CA 95201.0388 I209I 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - (CBmpi m in Trip6ub) APPLICATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE/S1,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI {p7{I7 Ce/Or/2/ �-+oco�C� J� C, A -41-n b LOT OWNER'S NAME D r is /�T ADDRESS �+/� �1 I�. �{ ��OH LCJ LC7 PHONE � /¢ y5 CONTRACTOR 4-, 7L�P l �T�WV ADDRESS �c1�L-ply � t„i/7 mi7y UCF PHONE SUB CONTRACTOR i� J /��//f/--p IADDfiE66 �D t /70 C 1 Y UCIc� PHONE 1-:5 / TYPE OF SEPTIC WORK: NEW INSTALLATION 19 REPAIR/ADDITION DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEEK T-TI.1 I I NOW MANY APO-b.. INSTALLATION WILL SERVE RESIDENCE IR COMMERCIAL❑ OTHER❑ NUMBER OF"NO UNITS:(NUMBER OF BEDROOMS:--1 NUMBER OF--Ym N CHARACTER OF SOIL TO A DEPTH OF 3 FEET: ,V PTlSUMP 601E CHARACTER: /WATER TABLE DEPTH SEPTIC TANIC-LASE TRAP ❑TVPELFG CAPACITY C' NO.COMPARTMENTS WO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL /CD-"— FOUNDATION-4: r'ROPERTY UNE LIFT STATION❑�cSIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM)�— {�� _ LEACHING LINE u NO.S LENGTH OF LINES -4!a r� DISTANCE TO NEAREST:WELL 7'rF UNDATION C:'O PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE [p MOUNDED ❑WIDTH LENGTH_DEPFH 1�p DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE rL (� —AGE RTS 11 DEPTH SIZE�(�NUMBER V DISTANCE TO NEAREST:WELL1'S-p f UNDATIONPROPERTY LINE/v yN SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TH16 PERMT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOPRMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU&CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS BUWECT TO WOWMAN'S COMPENSATION LAWS LLAA`YWSSOOF CAUFORNIA.' THE iAPPLICANT MUST CALL 24 HOB IN ADVANCE FOR ALL REOURED INSPECTIONS. COMPLETE DRAWING BELOW. � SIGNED X L/''J l /�4CJ[/ __ TRLE: � � DATE: 4 I PLOT PLAN(DRAW TO SCALE)SCALE 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF 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. O � Alp r , . ol00 h cr R � v 17 V' Z 8:; BEIri SIJ /// / FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED By /� / / l2.tiT/ n DATE: �1?��R� AREA: -AML/'7T O/l SUMP INSPECT(---0"'NIII BY / � DATE rf FINAL INSPECTION BVD T ATE /12 ! l� ADDITIONALCOMMENT6: ✓ c // -/¢� T v ole ACCOUNTING ONLY: AID( FAC• Qd PE CODE FEE INFO AMOUNT REMITTED HEC IC ASH RECEIVED BY DATE SR I PERMIT NIANBER INVOICE IF TJ D C4'All r)50 0 3 3 a r� SySr�P-