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APPLICATIL—LIR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O,BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 (209)460"3420 ' NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complftf in Triplieftf) :ATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN It JIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. r1,. IC"KDDRESS/OR ARN/ /(✓ G(L �T (,p /C..t[ CITY L�C'l.c LOT SIZE --'" ,, )WNER'S NAME A'(- _ ADDRESS / ,�/%/CyI..0 PHONE .I RACTOR__ C/77�/LsR �C� G ADDRESS_ �� C,A �'/ �C�J• • /ICI / �L y PHONE ) :I_ONTRACTOR ADDRESS LIC/ PHONE YPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPNRIADd TION DESTRUCTION❑ _PITC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUIL ING.) PERC TESTI.1 1 I HOW MANY APPII-BOO/ J.TALLATION WILL SERVE: RESIDENCE w COMMERCIAL❑ VTHER❑ UMBER OF UVINO UNITS:_/NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: _ 1- -ACTER OF SOIL TO A DEPTH OF 3 FEET:k �I PITISUMP SOIL CHARACTER: lG04,1, WATER TABLE DEPTH I 'TANKIOREASE TRAP ❑TYPEIMFD CAPACITY NO.COMPARTMENTS /o ,- I_REATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑jSIZE TYPE OF PUMP` SAND OIL SEPARATOR IENCLOSED SYSTEM) �2 / v" rr NO.6 LENGTH OF LINER_ � EACHING LINE /-yU �'/L.L_ D16TANCE TO NEAREST:WELL,:: � FOUNDATION L� A PROPERTY LINE 14� I I I BED EJWIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE fFr I DED F❑�WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE_ EEPAGE RTS u.IiOEPTH 25/ SIZE '' NUMBER U^� DISTANCE TO NEAREST:WELL!Z FOUNDATION O PROPERTY UNE UNIPS (/❑-WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE n I SAL PO NDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST WELL FOUNDATION PROPERTY LINE I�BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MRH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULE ND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH HIB IT IS UED,I SHALL PLOY ANY PERSON IN 8 CH A MANNER AB TO BECOME SUBJECT TO WOMMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR US ONTRACTING NAC IFIE THE FOLLOWING:'I IFY THAT IN THE PERFORMANCE OF THE WON(FOR WHICH THIS PERMrT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO / MAN'S COMPE TIO OF C IFORNIA.' S LL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW./ !r /� IV X TITLE: SIJ 1'L..l"//C ,�T DATE: 41)'-/Ec- V/ PLOT PLAN IDRAW TO SCALEI SCALE '[o MES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED TUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. AENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WETHIN RADIUS OF ONE HUNDRED FIFTY FT.ON ML*LUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ,v w 'j; HP4t' )2233 C, /O/Li �(J71L FOR DEPARTMENT USE ONLY n ^� 'PLICATION ACCEPTED BY � // �( DATE: /`� - ,,/� AS A: INK. -Pt SUMP INSPECTION BY E DATEIV``I/✓l INAL INSPECTION B� J/2 DATE IONAL COMMENTS: ACCOUNTING ONLY: AID) FACT COOE FEE INFO AMOUNT REMITTED HEC /CASH RECDVED BY DATE SRI-IT NUMBER INVOICE/