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PAYMEN-f APPLICATION FOR LIQUID WASTE PERMIT RECEIVED Smv JOAQUIN COUNTY PUBLIC HEALTH ScRVICES ENVIRONMENTAL HEALTH DIVISION NOV ] 206 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 SAN JOAQUIN COUNTY s8 PUBLIC HEALTH SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED QM►�j�T6l HEALTH DIVISION (Complete In Triplicate) //'�- �� (-% APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE wrrH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 4G JOB ADDRESSOR AAPP^N/ el,,(�� r �' 0�p JV LAJ C� CITY i LOT ]SIZ fE^'� / OWNER'S NAME lY I "7"`'� t+P�'�l.'C�� ADDRESS �i�I PHONE 36/ - 1 ( •��O CONTRACTOR .�CJ/�/ �'y ADDRESS Z� `•C G�Jf.C.%f�' �" �j UC/ PHONE !e Y: - SVS CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RFPAJR1ADDfTI-,114v DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)1 1 HOW MANY `�,..,/�. App$oetlon/ INSTALLATION WILL SERVE: RESIDENCE lea COMMERCIAL 11OTHER ❑ NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS- NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF J FEET(/-a" J#TLCW WT/SUMP SOIL CHARACTEIIc?/14y WATER TABLE DEPTH SEPTIC TANX/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE )91 NO.a LENGTH OF LINES /''Lf C}� /i V e— DISTANCE TO NEAREST:WELLl4710 f,- FOUNDATION f� PROPERTY LINE �Ut� FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED eee�❑yWIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION�y PROPERTY UNE ` T SEEPAGE PITS DEPTH 7 SIZE �' NUMBER DISTANCE TO NEAREST:WELLI�D/ FOUNOATION?Q ( PRLI (0O 74- SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. ME-9WNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM 18 ED,I=NOT EM NY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SVB-CONT CTINO GNATURE CE S THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMN'8 COM ATpN 9 OF CAUFORNIA.• THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$. COMPLETE DRAWING BELOW. \ ` SKINE3 TITLE: �� DATE: /�• O0 PLOT FUN(DRAW TO SCALE)SCALE_ 1. NAMES OF ST 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, S. LOCATION OF WELLS WITHIN RIIDR/S OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. iV ..:... .... _...... .. ..... . :. ..: .. .. .. .. .... .................. V=d arra .. . , W. � ............. 1111 :lil' + 1 W iiiiid' Ni10 . . ,......... _.... .... �, �/! ..... . ... . .. ... .__ �o .... : .. .. .. ....... ...:.....:. ...... ....... . ..... ...... ........ ... ... ...... .:..... . ... ... ... :.. .........:......: ................. ... ......:.....::. .. ..:..... .. . ... .. ....... ..... . ..........::.... .:.. . :......:......:.... ... :........... .....: ..... .: .. .. ...:.... :... .......:......:.......:.......:...... . loos ................... .... .... s r _ . .. V , - 01 ` +t� . — .. J ��'� '' "s