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APPLICATION FOR LIQUID WASTE PERMIT �; c/)U 'OAOUIN COUNTY PUBLIC HEALTK /ICES r' ENVIRONMENTAL HEALTH DIVISION �. 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CRmpNtR In TriplieRtR) APRICATION 18 HERESY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPtEEn 9-1110.3 AND THE 6&STANDARDDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH/SERVICER,ENVIRONMENTAL HEALTH DIVISION, JOB ADOnFSSron APNO PSS 3 li- ✓,L'L4/ X A'-b 3 -Z/0—/0 CITY 4&'I)/ LOT SIZE f /4L OWNF.n'S NAME p�A IV41 /,0c9�( A1,1/ 1V I Z 7p/ AODRESS 17-1.53 /(J JI �LVN Y PHONE L 3 i� Z/7- CONTRACTOR KU'\LT/TV CLI/L�1�--LCL /N-I` ADDRESS �ZgS J/, F/YJFI2�(LI� /lop LOCO PHONES Z7'�4'fU SVS CONTRACTOR ADDRESS UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ IMO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST-I I I NOW MANY AppNmfon# /Y 1� INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTIIEn ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT MANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHINO UNE ❑ NO.R LENGTH OF LINES DISTANCE TO NEAREST!WELL FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE MTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PF1OPEnTY UNE DISPOSAL PONDS ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF TI/E SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'10ERTIFYTIIAT INTHE PERFORMANCE OF THE WORK FORMRICH THIS PERMS IS ISSUED SHALL NOT EMPLOY ANY PERSON BI SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTINGI! S TURF CERTIFI E FOLLOWING!'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IR ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM 9 TION��FORNIA.' THE APPLICANT MUST CALL 24 HOISL!IN ADVANCE FOR 'ALL /RErGnWIFD INSPECTIONS. COMPLETE DRAWING BELOW) �I 9 SIGNED X �y TITLE: V • I DATE! OT PLAN IDRAW TO SCALE)SCALEL% 564 -Ie 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF T14E 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. PA ReEi- 1 �A1ZCl;L � � (trK. 11VEiL ....... S11EEr►ENs o- PF_Re--mE r • __ ............ . - .. f ERC'(EST Si o {SPR 2 l) ppr4.w= f#t7US� � _ a1fvJ Ii`'tJ1,tVlVaW;iTtllt)t KT!V1F1(`NMrNTA 722/ ��y neA `�/�w ' r, `'^�\\ FOR 'DEPAP ENT USE ONLY APPLICATION ACCEPTED nY , 'y�'vWC.� �'W14 / ��/�[/ � DATE: /9 AREA: < 1 TANK,PIT On BUMP INSPECTION BY / DATE / / ^ FINAL INSPECTION BY /� �/ , - DATE ADDITIONAL COMMENTS:_ ti U I ♦ 1 I� 'I �- /`�I ACCOUNTING ONLY: AID# FAC# 7p Etco2- FEE INFO AMOUNT REMITTEDICK /C# ABH RECEIVED BNLUMY DATE RR IPERRINT BER INVOICE# p SSI 1S Pub.Health Serv.-Enviro.174(3196)