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SAJO'PLICATIOA FOR LIaUIO WASTE PERMIT AQUIN COUNTY PUBLIC HEALTH SEf�CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA952(: Opy (209)468.3420 MON-REFUMDARE PERMIT EXPIRES 1 YEAH FROM DATE ISSUED (Complete In Triplieatel APPLICATION 18 HEREBY MADE TO THE SAH JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN 4 JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMB10N. CITY LOT SIZE JOB ADDRESSAIR APN/ f/k/ IL L/ 4e w!' EGlit OWNER'S NAME AiLe K7/.Aik—e/N ADDRESS MlQ ADDRESS jaz CONTRACTOR W• L tJi1i l*� r_LICI Fes/ 3� vHONE� f)33 r3 sun CONTRACTOR ADDRESS .. UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADOITION ❑ DESTRUCTION ❑ M SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) F'PZ1C TESTIQ I 1 HOW MANY Apoeosdon# INSTALLATION VIII NERVE: RESIDENCE❑ COMMERCIAL❑ OTHER❑ - NUMSfft OF WINO UMTS: - NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES,- -- I CHARACTER OF SOIL TO A DEPTH OF,FEET: PITlSUMp SOIL CHARACTER: - WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ©TYPE/MF-0 CAPACITY NO.COMPARTMENTS PECO TREATMENT PLANT 0 INSTANCE TO NEAREST: WELL - - FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR IENCLOSED SYBTEMI 'LEACMNO UNE 13 NO,■LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER RED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH bEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 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 WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGEHT'9 SIGNATURE CERTIFIES THE FOLLOWING:11 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH TIi18 PERMIT 19 ISSUED.1 SHALL NOT EMPLOY ANY lFIPF9t1CFT'A MANNER AS TO BECOME SUBJECT TO WpRKMAH'9 COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIER LLOWING:'I CERTIFY THAT 1k THE PERFORMANCE OF THE WORK FOR WHICN THIS PERMIT 16 188t1ED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS ALIFORMA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECT10N6. COMPLETE DRAWING BELOW. SIGNED% TIRE• DATE: PLOT PLAN(DRAW TO SCALEI SCALE_ -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISMBAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM8. 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 MEAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ..., ..:.... ..:.... ,...... ---.:... ... .. ... .: E - ...... .....'... ................. °.. ........ r �r .�a,.. TSS ..... .. .. . . ....7. .. _ ' ..... .................. ...... 1n .. - ................... .................. ......... ... ............... "Qq. f ... y1L ... ..... ............ ... . . :. . :. ..:.... .. . - . . :...... ....... ... ... .. .<. . .. 0 . .. .. .. ... .... . ....:.....: . - .. .. - .. : - .. SHIo JC1 PUStJC H H SERVO ES 6NV! <.....:...... .....:............ `..................................................... .... HONME ENTAL HFALTH DIVipoN, - POR DEPARTMENT USE ONLY �.. APpLICATIdNACCEPTEPeY _ — DATE: `P �C.�,�j _ - AREA: - DATE� �_FINAL INSPECTION BY hl� DATE !1 1 -99 TANK,PIT OR SUMP ONSPECTIO14 ADDITIONAL COMMENTS: - - ACCOUNTING ONLY: +UDR FAC# r PE CODE FEE INFO AMOUNT PAM ITED' HEC !CASH RECEIVED BY DATE SR I PERMIT HIAMBER INVOKE# L Pub.HeaMh Sero.-EmAro.174("6)