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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201.0368 <br /> (209)460-3420 <br /> NON•REFUNOABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> PaWlw in TripNEBeE) <br /> APPLICATION IS I41748y MADE TO THE BIW JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOfl INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMFVANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TTTLEE�CHAPTER <br /> /5-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVIBK:N. <br /> JOB ADORESSfOR APN/� /a<�J"�rJ� K Cm <br /> -}��J _LOT EIZf�� <br /> OWNER'S NAME lL•�i �r- ANSS11­1-1 . <br /> (� / ^' PHONE <br /> CONTRACTOR Q orfC'/Y e, ADDRE r c <br /> PHONE <br /> SUBCONTRACTOR ADDRESS <br /> uC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPALWADOITION DESTnmT10N❑ <br /> IPSO SEPTIC SYSTEM PERMITTED IF PUBi1C SEWER IB AVAILABLE WITHIN 200 FEET OF BUI NG.) FERC TESTNI I I NOW MANY <br /> App11o4Son/ <br /> INSTALURTjDN WILL UWL- RESIDENCE❑ COMMEACIA g OTHER[I <br /> NUMBER OF LIVING UMTS: NIMSSR OF SED"DCMS: N IMSER OF EMPLOYEES: AZ Q <br /> ^! V <br /> CHARACTER of BOIL TO A DEPTH OF 77 FEET:6A14 pTTfSUMP SOIL CHARACTER:_ WATER TABLE DEPTH `• •i-• <br /> SEPTI[TAN% _f-i TR/V LL TVPFIM. L- CAPACITY NO.COMPARTMENTS_ <br /> PILO TTIEATMETFT PLANT 13DISTAN/C•E TO NEAREST: WELL-7-s-f <br /> ELL9Sr <br /> FOUNDATION In ' ppOPENTy UNE � <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING UNE ❑ NO.S LENGTH OF LINES NES DISTANCE TO NEAREST:WELL FOIMDATION PROPERTY UNE <br /> FILTER SED A WIDTH_LENGTN��DEPTH_4Mf dSTANCE TO NEAREST:WEIl���jr� tPJRRIpATION J f <br /> PROPERTY LINE_ <br /> MOUND® ❑WIDTH UNGTH _DEPTH DISTANCE TO NEAREST:WE11 _FOUNDATION PIOpERTy LME <br /> SEEPAGE PITS ❑DEPTH 8QP NUMBER DISTANCE TO NEAREST:WELL _FOUNFDATION PROPERTY UNE <br /> STNV 11WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL_ FOUNDATION PROPERTY UHF <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THC WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OPDWANCES AND STATE LAWS,AND RULES <br /> AND REGU.ATR/NS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S 81GNATURE CEATIFIEB THE FOLLOVJM:.1 CERTIFY THAT IN THE PERFORMANCE OF TIRE WORE(FOR WHICH <br /> THIS PERMFT'18 ISBUIED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKNJAN'S COMPENSATION LAWS OF CALIFORNIA., CONTRACTOR'S HIRNG OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOU"WING:-1 CERTIFY THAT IN 1 HE PERFORMANCE OF THE WOP K FOR WHICH THIS PERMIT 10 ISSUED.1[affALL EMPLOY pERSONB SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIIlFORNIA.' M MIST CALL 24 HOURS IN ADVANCE FOR ALL REQUIP.INSPECTIONS. COMPLETE DRAWING BELOW. <br /> SIGNED% :J L- )�' TITLE'- .E---IGS DATE:1C"r dL <br /> PLOT PIAN(DRAW TO SCALE)SCALL:__'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDNG THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED RPrY FT.ON <br /> INCLUDINO COVERED REAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY• <br /> ...... <br /> '•I I <br /> AA <br /> - <br /> 77 <br /> . .. .. . . . .. <br /> N <br /> .�... . .. <br /> �.. <br /> a r <br /> "I• <br /> x <br /> •F' <br /> ...E. ..i....>.i. f ..;... ` <br /> .w <br /> I <br /> _.. <br /> 4'�•...�'..I.L.I. E �...!... .. :.. :�:' --... ':�•. :I. <br /> g3 <br /> t <br /> a I <br /> z.. <br /> 2 . .. ........ <br /> 0 f <br /> I <br /> 1 <br /> I <br /> :a <br /> — <br /> .. aN1 <br /> —T .. <br /> CT <br /> .................. ......:.:...' <br /> - - <br /> ,r1GAY <br /> fFAjTsLL <br /> —�.. -^•-� •1 __ '^IFA _ <br /> FOR DEPARTMENT USE ONLY n <br /> APPLICATION ACCEPTED FY DATE: 1 r <br /> AREII_� <br /> TANK,PIT OR SUMP NUPECTION BY DATE I!�-FINAL INSPECTION BY DATE /O <br /> ADDITIONAL COMMENTS: - <br /> ACCOUNTNO ONLY: APF FAC/ <br /> PE CODE FEE INFO AMGVRT REMITTED CLEC 1CAEH RLECEVTD BY DATE M f pEONT NlMtgl R/VMCE F <br /> L' 6 6 0- <br /> <D/Y1r1 F7 etW <br />