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APPLICATION FOR LIQUID WASTE PERMIT S,.&JOADU' 'OUNTY PUBLIC HEALTH SERVICES ENV (ENTAL HEALTH DIVISION P.O. BOX 3BB, 446 N. SAN JOAQUIN ST., STOCKTON,CA 96201.0388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplsts in Trpliostsl APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORT(DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WrTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAP//TyyER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. / JOB ADDRESS/OR APNN [✓ CITY �y/��L� (� .} LOT SIZE/Z OWNER'S NAME �j /' ` ADDRESS 9(./ L //[� !� }+,,r�+ / �'1 , A//�/yr PHONE '7 ,.ry CONTRACTOR/ )' A� x7'Jl ADDRES996L7 E, L ml;,ofljlI(--�.�%"91�a'YIc, /Z.� - //.=/.PHONE /f''J—Lam''17V7 SUB CONTRACTOR ADDRESS +�.48�F' / ` XNE `e'� / -I r te( TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 300 FEET OF BUILDING.) PERC TESTW L I HOW MANY APdloetlon I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL[3OTHER❑ 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 PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.A LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SLMRPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE S- DISPOSAL PONDS ❑WIDTH LENGTH DEPrH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE C I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OFTHESAN JOAOUINCOUNTY.HOMEOWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'ICERTIFYTHAT IN THE PERFORMANCE OFTHEWORCFORWHICH _ 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 HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED% V \ / r ,Z.., r'^I' t C'd..{ .-.F TITLE: C.�-.�Y .//L.e/��/�f i��/DATE: T 91 PLOT PLAN(DRAW TO SCALE)SCALE 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. DIMENSIO NFO nil I ucc eun i nr ennu nF eI I FISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCL Z�9� 3ep. 50 40 N SO 4c. SO 4,. b\ r t✓T „ . 11' k' 11p1E1pi* p� o s{r°G in Pomace/ l s.o A.. - Poke/ 3 0 h m J U L 1 9 1996 c,AN JuAGUIN l.Gl;rJ)r 500 ES LCL V,/�/ !�' _' FOR DEPARTMENT USE ONLY q APPLICATION ACCEPrED BY �� DATE: I AREA: TANK,PIT OR SUMP INSPECTION BY /DATE / / FINAL INSPECTION BY '� DATE / y/ ADDITIONAL COMMENTS: �Y - .J V �'" J �- c //tom ACCOUNTING ONLY: AID( FAIN �T / PE CODE FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE bR/PERMIT NUMBER INVOICE N a Sa I a / ]�!:= 09 .6 030