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APPLICATION FOR LIQUID WASTE PERMIT SAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 488.3420 .� N0111-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HENRY,MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DESCRIBED- THIS APRJCATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. .JOB ADDRESSIOK ARNa l�J"1�J� �,�.1k7Ie }l 1 7 •1 CRY �� 4 ,Y�r.,.YT-a- LOT SIZE I CSX. OWNER'S NAME_L•,kw�J2 JT7 ADDRESS_ CONTRACTOR ��.-3�� y0�7 ADDRESS . i\, rSUR CONTRACTOR _ 11Ce '� •� I RWNE a . L_a 2 O 3 AOOREBB UCP PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIRIADDITION ❑ DESTRUCTION❑ ,_.ONO SEPTIC.SYSTEM PERMITTED IF MNUC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.( PEIC TESTIFI I 1 HOW MART INSTALLATION WILL SERVE: RESIDENCE 13 COMMERCIAL e COMMERCIAL ❑ OTHER ❑ NMAaq OF LINMO UNITS:_ NUMeq OF BEDROOMS: 'S NUMaq OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OFF33 FEET:C 1 4.1 MMUMP SOIL CHARACTER:C Y FTY �l:�e_J WATER TABLE DEPTH 7 j' SEPTIC TANKGffl ABE TMP Ly TYPLwFO-_�crlC_ CAPACITY_ G:C^C� M. COMPARTMEMB PKO TREATMENT PLANT 11 DISTANCE 70 NEAREST: WELL J C•C• ' FOVNDATION PROPERTY LINE 41.v ' UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM, LEACHING UNE O NO.B LENGTH OF LINER C 3 PT DISTANCE TO NEAREST:WELL /L C ' FOUNDATION_ r ' FROPERTY UNE /f:C ' FILTERFILTERD ITSEO ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FpUNDATgN PROPERTY UNE �AOUNOfp ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION RK)PERTV LINE SEEPAGE PITS EB-DEPTH ') 812E DIRANLE TO NEAREST:WELL /SZ'" FOUNDATION i/ PROPERTY LINE i[•(� ' owes ❑WIDTH LENOTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE r =ISPOBAL PONDS ❑WIOTN 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 BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFYTHAT N THE PERFORMANCE OF THE WORK FDR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO%YORLMAN'Y COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUR-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS HISUED,I SHALL EMPLOY PERSONS SUBJECT TO �NOR(MAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS. COMPLETE DRAWING BELOW. `SIGNED% i � �,Tl. . .'� l �_ C-1 ilG7 < �110TL.)( TITLE:_ !`'o J .'-1N .f DATE: Vis-_44- MOT 4-ROT MN(DRAW TO SCALE)SCALE •,y 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BY/TEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL WSTEMS. O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PIIOPOSED STRUCTURES, S. LOCATION OF WELLS WTIHIN RADIUS OF ONE HUNDRED FIRM FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DNWWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. Irn SEP 2 4 1998