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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complate in Triplicate) APPLICATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AOURESSlOR APNN /r. cT�� Q q X`— OWNER'S NAME_ -�j�)'— „G L.j�� /4i»7a,"'z" ADDRESS /7J l� 4 /�`��C-.t/l lC�. 2/-- ��LX/,,I--7 PHONE CONTRACTOR I--7,.,�r�n /p•S/ � AD1)RE6S�G? [:,jFI/��'J� j`��/ i C#�C 144e', PHONE SUB CONTRACTOR ADDRESS 11C# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADEXT10N ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(.(( I HOW MANY APplloellon#'01,51 ..•�. �U INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ 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 TANKIGREAGE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.6 LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PIT& 11 DEPTH- SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH{ DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I 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 TIIE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WI{ICII THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S/))RING On SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REG(IRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNEDX l / I/ " / 4ili ✓Yti �✓iYa� TITLE: /Y�1 /7�///r'(`'/ DATE: PLOT PLAN IDRAW TO SCALE)SCALE •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMEN n ATl(1N OF ALL EXISTING AND PROPOSED STRUCTIIRFS. INCLUD I ry� 1N o h (ur+BBt,O BRB Mt-RS Pr 6/-JIG-0.1 lu'wS,O b+J MCRS /� PARCEL N0. 1 80.0 ACRES 4 r„ r.noR o •PY.a-uo-o5 F O 4 F I / P 9yO. %I• A.c,r,,P.....wo Ulk �] 2 P.�al-JIB-01 rC/+M' HC.IXa A -- N 139'30' E 1300'3 APe 4r-Jlu-x • 335'±--0'±-. - 83 1 \A I S 83'E 980" I ... _ --'"'150't... i .. s>z11 \ ,9 N 17'39' E...._:' S I 300.00' } 7Z 1 S 61' E... ,v.•ar-]10-BS Q - 55 I 235.3' L \'� PARCEL N0. 2 ,y I 3 n SCALE 1" = 300' S 75'52' E- ... L I 80t ACRES 2. Z 258.0' 3 3 7.90: I S 53'32' E \\� 41 H '0 224.0' 0 S 45'00' E...• - >♦ 450'3..'.1. ( 290.0' I S 59'17* E...''1 "" ' 278.0• I .'. ,P N. il-l30-I. S 67'2 E" ........ �1 190't....., r 104.0 1 S 74'40' E...-.' 135't..., '.+ 3713.4' I1 S 5911 E..... I ' _...tENree of SECTION 5 V 1/4 Cott. SEC. 5.- 1 332.0 _ N 88'40' E 1315'3 .'........, ! rt/4 SEc.uNE.... 5 83'20' E..... � RIVER .1/16 SEC,Cat. I 275'3 CALA E1% . / F" sroarrcw[,sr�,r�azr/ PF CEL LOCATION..... l) P mm1, 1996GENcRAL 1. REFI 9�y1V• "°. /y.,/ CK,�' I 2. THE o� l.l�l1 Y3. seg I'Ll(jLIC f jEAl.l1 i ': STK �NVIRONMFP11 �! i�f:81 III Ill!8; ELE APPLICATION ACCEPTED BY i DATE: L � ) AREA: -? �y TANK,PIT OR SUMP INSPECTION BY DATE 1 / FINAL INSPECTION BY r✓L tf� /`� DATE �� / ( / C ADDITIONAL COMMENTS: yJ//yam-"P t' ��3/y/p�/0) 3 9 Yo ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BYDATE SR/PERMIT NUMBER INVOICE 1 ? � L