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r 4r7 ••• • ,••••• APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388,304 EAST VVEBER AVENUE, STOCKTON, CA 95201-388 ROB/ 488-3420 SEDROOMIP INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL 0 NUMBER Of LAAND / NUMBER 0 SIGNED /I TITLE DATE: FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY OATS: MON-REFUNDABLE PERMIT WIRES I YEAR Foam BATE SSUED (Coirtpkte is TrArikats) APPLICATION PS HERESY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR *MAU THE WORE DESCRIBED. THIS APPUCATION IS MADE IN COMPLIANCE wrn4 SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH %RVICE13, ENVIRONMENTAL HEALTH DIVIS/ON. JOB ADDFEES/OR AFTIF 4/0 11 ttkinOrs -icl Lar CRL) crre firri/fri,e) OWNER'S NANIE Cur- ADORERS 17 9o/ LIR g r vA0 pHop. 74/5 -15/5 CONTRACTOR I HERESY CERTIFY THAT I HAVE PREPARED T1119 APPUCATION AND THAT THE VVORC WILL. OE GONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS, ANO RULES AND REGULATIONS OF THE SAN JOAQUIN cowry. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT SURE PERFORMANCE Of THEWOR(FORWHICH THIS PERMIT IS ISSUED, I SHALL HOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOEWMAN'S COMPENSATION LAWS OF CAUFORNIAT CONTRACTOR'S /BRNO OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COEAPENSATON LAWS OF CALIFORNIA.• THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGIME° INSPECTIONS. COMPLETE DRAWING BELOW. oungucnom Q TYPE OF SEPTIC WORK: NEW UNIT AllA710N 0 ROONIMADOITION 0 NO SEPTIC SYSTEM DERiarrtco IF PUBLIC SEWER IS AVARARLE WITHIN 200 FEET OF BUILDING.) IL CHARACTER WATER TA6tE DEPTH CAPACITY 2s1 FOUNDATION LIFT STATION 0 SIZE TYPE Of PUMP SAND ON. SEPARATOR (ENCLOSED SYSTEMI DEPTH DISTANCE TO NEAREST: WELL DEPTH DISTANCE TO NEAREST: WEIL_ NUMBER DISTANCE TO NEAREST: WELL DEPTH DISTANCE TO NEAREST: WELL DEPTH DISTANCE TO NEAREST: WELL NO. COMPARTMENTS PROPERTY UNE //60 FOUNDATION vo PROPERTY UNE FOUNDATION PROPERTY LINE FOUNDATION PROPERTY UNE FOUNDATION PR3FERTY ONE FOUNDATION PRoPenre UNE FOUNDATION PROPERTY UNE CHARACTER OF SOS. TO A DEPTH OFT FEET; . • 0. SEPTIC TANK/GREASE TRAP 0 TYPE/MPG 110411/1PWAFJJ PEG TREATMENT PLANT 0 DISTANCE TO NEAREST: WELL 11, LEACMNO UNE lit NO. a LENGTH or UNIES ....3 - 41' C_Ii/r5 IlLT131 BED 0 mum LENGTH MOUNDED 0 WIDTH LENGTH SEEPAGE PITS kbevrti 2—,-'-1- SIZE 3e," SUMPS 0 WIDTH LENGTH DISPOSAL PONDS 0 WIDTH LENGTH DISTANCE TO NEAREST: WELL /60 75- OTHER 0 NUMMI OF RAPLO PLOT PLAN (DRAW TO SCALE SCALE TO NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. OUTLINE OF THE PROPERTY, WITH DIMENSIONS AM) NORTH DIRECTION. DIMENSIONED OUIlJNES AND LOCATION OF AU. EXISTING AND PROPOSED STRUCTURES. INCLUDING cowmen AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAIXE ADDRESS / 2/ E A25711Ci• 4e4/275 FMNERPDNE eT /h 9LA1 CONTRACTOR 74/tp., ADDRESS ' . • • .... . ........ ..... ... ' .. ' .. ' ' ' ...... ..... ADDITIONAL COMMENTS: / TANK, PR OR BUMP INSPECTION BY OATE / FINAL INSPEC ION BY 21// cArdo I/9 /ft ACCOUNTING ONLY: I MOO FACE PE CODE FEE INFO AMOUNT /EMITTED CNECIONC AMI RECEIVED MY DATE SR / PERMIT NUNIIIN1 INVOICE S y2.11 115 (O cr) 3f5 7 ,-/ L.4 /6//ziq' 0 / 7 1 (1-, SQ.oalnk66 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS, N. LOCATION OF WELLS WITHIN RADIUS OF ONE HUMIRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. PAW PIPIC TESTIII I I NOW MANY AmslIeWlart •