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PLICATION FOR LIQUID WASTE PERMIT _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t- R ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 I 4683420 NONREFUNDABLE PERMIT IT ERPIBES 1 YEAR FROM DATE ISSUEDCap (Complete in Triplicate) APPLICATION IB HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN C 7 OMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE..]CHAPTERy9-11�1�1�0.3 ADNg1/THE STANDARDS OF BAN JOAQUIN C-OUINT PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR AnPNAI O 17 11"1 O /�{'A�'^` 1(J / I [-5 S r --o oW SWC' /�/m, 5'T/T I,1rL,I�/ � LOT SIZE OWNER'S NAME DILL- 4EN�J ADDRESS3�C) 11T' f�r�QLL 6u/D �i�-T` f7A 9y5`1 'LIDNE CONTRACTOR jjjQfi 1,) d' f} C 1 I FJC ADDRESS ZZ Ia. jjosi 571f1.) 4-.Aj (.ODI (?4w LIC#C-'t0`700q PHONE 367-3;,0! SUBCONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPMR)ADMIGON ❑ DESTRUCTION ❑ / (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDINOJ PEIC TESTI.(1 I HOW MANY 1� APdI••xon a INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALS OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF J FEET: PfT/SUMP BOIL CHARACTER: WATER TABLE DEPTH �O SEPHC TANK/OREASF TRAP ❑TVPEWFO CAPACTTV NO.COMPARTMENTS PKG TREATMENT PLANT❑ GU TANCE TO NEAREST: WELL_ FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACHING LINE ❑ NO.6 LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPEnry LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEARERT:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:MELI FOUNDATION P PETTY LINE SUMPS ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNOATION 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 WORK WILL BE DONE IN ACCORDANCE MRH BAN 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOY EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-COMRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATI 9/OFFF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR AAJLLLJ AEOUIRED INSPECTIONS, COMPLETE DRAWING BELOW. SIGNED X TITLE2 /5 DATE PLOT PIAN(DRAW TO SCALES SCALE 'I. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPEITV. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL S)`STEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WRHIN RADIUS OF ONE HUNDRED FIFTY IT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALK$. THE PROPERTY OR ADJOINING PROPERTY. tfwY 99 N N 3 4i w I k43 ? DR: .! PU I q Sic A1TH$EHU-(�I W \ V) F -Cw l SIV Kp T USE ONLY � � �/I APPLICATION ACCEPTED BY ,wl/1�, DATE: 1`i AREA: �� 99 / y-1��• TANK,PLT OR SUMP INSPECTION BY DATE / P FINAL INSPECTI0 V DATE/OF. / 11/ 1 ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# PAC# PE CODE FEE INFO AMOUNT REMITTEDHEC PLASH RECEIVED BY DAT SII/PERMIT NUMBER INVOICE F '71,y