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APPLICATIOP LIQUID WASTE PERMIT SAN JOAQUIN C TY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)4683420 OK• UNDADLE PERMIT EXPIRES I YEAR FROM DATE ISSUED �.. ICBIRPIBtt M Trblkatt) f I t �:- APPILIATION 10 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION It MADE IN COMPLIANCE WTTI/BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVKEB.ENVIRONMENTAL HEALTH DIVISION. e AOOfRE$e/DR AMPA'r /,'-t - I�1 `-CITY I, LOT SIZE ' VNER'S NAME 1` I I'i G i 1�.1 f !_C 11', ADDRESS t! I i`'.\•_'. .;I /I PHONE CONTRACTOR' I /C ADDRESS / I: I C' LCS RHONE IS CONTRACTOR ADDRESS LRCS PHONE PE OF SEPTIC WORK: NEW INSTALLATION,❑ REPAIRIADDITION ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PU8L1C SEWER IS AVAILABLE WITHIN 200 FEET OF SUILDIN0.1 PERC TESTUI I I HOW MANY O f APPYstlen I 17ALJA71ON WILL BONE: RESIDENCE E3COMMERCIAL E3OTHER 11 MBER OF LAVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ARACTER OF SOIL TO A DEPTH OF 3 FEET: NT/SUMP SOIL CHARACTER: WATER TABLE DEPTH •ERIC TANKfORREASE TRAP ❑TYPEIMFO CAPACITY NO.COMPARTMENTS J PRO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE /yam UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR CENCLOSED SYSTEMI ACNNO UNE ❑ NO.S LENOTH OF LINES DISTANCE TO NEAREST:WELLFOUNOATON PROPERTY UNE -rot SED ❑WITH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE ^s, ---7AOE PTS ❑DEPTH S¢E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE AM ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE POSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND RATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUN COUNTY.HOME OWNER OR LICENSED AOEN T't SIGNATURE CERTIFIES THE FOLLOWING:'ICERTIFYTHAT NTNE PERFORMANCE OF THE WORK FORWHICH IS PERMIT IB ISSUED,I SHALL NOT EMPLOY ANY PERSON N SUCH A MANNER At TO BECOME SUBJECT TO WORKMAN'S COMPENNATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR 5 -CONTRACTING SONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PETFORMANCE OF THE WORK FOR WHICH THIS PERMIT It ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO 'P KMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL t.HOURS N ADVANCE FOR ALL REQUIRED INSPECTIONS.COMPLETE DRAWING BELOW- INCHED X ELOW.SIOHEDX 1•:RI i I�-�h--_.. TITLE:: DATE: _ PLOT PLAN CRAW TO SCALE)SCALE NAME$OF STREETS OR ROAD$NEAREST TO OR BOUNCING THE PROPERTY. A.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPOBAL 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 MEAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. n7-tso-1 r tLAC?(Y.RN ' SCC EION Vt " °` MONCURE ROAD — I .44AV qq N p 1 IS"34'(O'C SAM ACRS S(1 NI a 7-?g0 6 Ll7N�oc�_ e E�FIVED =, NOV 1� CLISIFR`ALMOND OK7'W11D SAN JO F eN IRONM HEALTH SE" <ES I I` ENTAL HEA p 4 � 7))-t10 RASION f AWDERW "DESIGNATED REMAINDER' e A 117.21ACfCSCROSS o R Pelt ll~"AWW"I ONLY 7I I .UCATLON ACCEPTED BY L V Uy l✓" �k A!V Yv v, DATE: L l I�' � I AREA: TANK.PIT OR BUMP INOKCTIO14 BV DATE l / FINAL INSPECTION BY DATE I l "OITIONAL COMMENTS: ACCOUNTING ONLY: NOS FACT f L� / K CODt FEE INFO AMOUNT RFMIITED INECKSJCASH RECEIVED BY DATE M/RMT NUWSER INVOICE S J MIL �)-'!Lr Pub.Health Se N.•EnvlrD.174(3/96)