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�. APPLICATION FOR LIQUID WAsrePERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX S88,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete iR Triplicate) APPLICATION 16 HEREBY MADE TO THE SAN JOAQUIN COVNTY FOR A PERMIT TO CON6TitVCT ANO/DR INSTALL THE WORK DESCRIBED, THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN — JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 13-11110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH MVI610N. JOB ADDRESS/OR APNA1 I_ I..� �L/ � rtr'L^A�/��l%1��ICRy 1 7`.(IrC(2`�}� LOT SIZE OWNER"S NAME ` )./` ISL h-I��` 1- 4ADDRE66 I ` RIONEI, li CONTRACTOR 1- I T7' l!'1..� i(.C !I. ADDRESS f J. �T.')�!i/I..0 r%ISI• ( ('1,) 1 • /•�/'�/l f/ PHONE SUR CONTRACTOR ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW IH6TALLATION� REPAOR/ADDITION ❑ DEATRVCTION❑ \ (NO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.$ FERC TESTI-I I I NOW MANY A,01-0o INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALO OTHEA❑ li NUMBER OF LIVING UNITS: NUMBER OF BEDROOMB: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEI C TANK/OREASE TRAP ❑TYPE"FG CAPACITY NO.COMPARTMENTS ' PKO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL _- FOVNDATION PROPERTY UNE UFT BTATIDN❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACNNO UNE ❑ NO.B LENGTH OF LINES DISTANCE TO NEAREST:WELL fO VNDATION PROPERTY UNE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE NTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SWAPS 11 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I 1 HEREBY CERTIFY THAT I HAVE FAEPAREO THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN CDVNTY ORDINANCES AND STATE LAWS,AND RULES iAND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNEROR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHATIN THE PERFORMANCE OF THEWD/K FORWHICH THIS PERMIT 19 ISSUED,1 SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR-11 HIRING OR + SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOWMAN'S COMPENSATIO S OF CALIFORNIA.' THE APPUCANT MUST CALL 14 HOURS IN ADVANCE FOR ALL REGIRRED INSPECTIONS, COMPLETE DRAWING BELOW. SIGNED% � v� ` TITLE: GATE: PLOT PLAN r[) 1W TO 6CALE1 SCALE 'to 1.NAMES OF STREETS OR 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 RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. _ i n rlAY WT 6 \J) DEC 7 1 r=19 9 (fi = �7 > 1-'_1 a:,r-:JOAOUIN C:CiUN!T i 4J � PUBUC HEALTH SERVICES _ ENVIRONMEN A(HEALTH OIV;SION _ 4 , J 1 f FOR DEP ir.1 T USE ONLY � APPLICATION ACCEPTED By Y• {� /L�/ �^ L'!`/VY.\� DATE: I� AREA- TAW.PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: ACCOVNTING ONLY: AID/ FACI PE CODE FEE INFO AMOUNT REMITTEO •C`�/CASH RECEIVED BY DATE SR/PERMIT NUMB E1 INVOICE ] / I