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3:aO O -S APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 55201.988 (209)488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TripReBnl APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APKJCAT10N 18 MADE IN COMPUANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1110.3 AND THE STANOARDB OFSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Joe ADDREssroR AeNF 1J�/ /` 'lclne, /�f( � CIYY /J�cf�Bd �L�OjT 81z�'E-zIf � OWNER'S NAME J�L.p�LtL /IL t'+WILT-,�(.�./(L y`. ADDRESS �� r��. /"CL ILEI"�,/�� P10NE3YJ 7] l T( 7/ CONTRACTOR ✓V LO eAzK �Y/.1T7eL ADDRESS)Z� G [_,//(,y1C�i�il� - �/Z- UCSVW22 PONE V-6L 52— BUB CONTRACTOR ADDRESS UCf RHONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPANVADDITON mrRUCDON❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILAW WITHIN 200 FEET OF BUILDING.) PYO TESTNI I 1 HOW MANY ApglaWon I INSTALLATION WILL SERVE: RESIDENCE* COMMERCIAL❑ OTHER 11 NUMBER OF LIVING UNITS:_NUM8E1 OF BEDROOMS:_,NUMNVA OF EMPLOYEE: CHARACTER OF SOIL TO A DEPTH OF 3 FEET /14. PIT/SUMP 901L CHARACTER:� LE WATER TABDEPTH MI SEPTIC TANK/ORFASE TRAP ❑TVPEFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION 11 SIZE TYPE OF PUMP $AND OR.SEPARATOR(ENCLOSED SYSTEM) ^T LEACHING UNE No.•LENGTH OF LINES �� CO I Y(!Z DISTANCE TO NEAREST:WEU 6 -f UG FOUNDATION O _PROPERTY NE Q/ FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAEST:WELL FOUNDATION PROPERTY LINE tP MOUNDED ��VTT777❑EEE WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE _1 SEEPAGE/ITS ,9 DEPTH�1 size ZV Ar 14UMM DISTANCE TO NEAREST:WELL.Toa,'" FOUNDATIDN—VLL—PROPERTY UNE SUMP$ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE O DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEATEST:WELL FOUNDATION PROPERTY LINE rn I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND RATE LAWS,AHD RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY' LICENSED AGENT'S SIGNATURE CERTW*S THE KKID AN0:'I CERTIFY THAT IN THE PERFORMANCE OF THEWORK FOR WHICH D THIS PERMIT IS 1 SHALL NOT EMPLOY ANL'PERSON IN B A MANNER A8 TO BECOME SUBJECT TO W WKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUbCOHTRAC O BON CE E fol WTNO:'I C THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSON8 SUBJECT TO WO/e(MAN'8 OMPENSA N O CA RINIA.- ALL 2e NOW IN ADVANCE►011 A-LL..11[OUMISD INSPBCTONS. COMPETE L7RAWttx1 BELOW. `/Q 8ONED X TITLE:�t}�['( DATE: iG�y'J / O POT PAN IDILAW TO SCALE)SCALE 'to i.NAMES OF STREETS O ADS ST TO OR BOUN04NO THE PROPERTY. S.LOCATION OF!OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED tv 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DHMENMNED OUTLINES AND LOCATION OF ALL E%NTINO AND PROPOSED STRUCTURES. N ES. S.LOCATION OF WELLS WITHIN RAUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALLS. THE PROPERTY OR ADJOBMq PROPERTY. C W11 �L PA YAVIE�j ,. t. i�96rr �( f2 4 P` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY GATE: MEA:�f� TAMC,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE �O 7"�7/ •b AODR/ON-COMMENTS: ACCOUNTING ONLY: AOI FACT PE CODE FEE INFO AMOUNT REMTTEO .7. ASH RECBVED BY DATE sR/PBMST INLAYER NvaCE- a *'41 L6 I)DIZ419 3a a