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APPL TION FOR LIOUID WASTE PERMIT SAN JOAl.;A N COUNTY PUBLIC HEALTH SERVICES �i67Z EN-iRONMENTAL HEALTH DIVISION P,O,BOX 388,SO4 EAST WEBER AVENUE,STOCKTON,CA 95201-M (209)4883420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comples in Triplie$t$) APPLICATION IS HEREBY 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,CHAPTER 9-1110.3 AND THE STANDARDSOFSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN/ h R N n - TTY 1{�AcAtArn CA LOT SIZE 14c OWNER'S NAME C O lr(r`Tc`�DRE63 P•U [7AX_�� IIE]rtda¢, 64 PHONE 33444�5 CONTRACTOR g[iiAmb4f�l ij CLQ-ZZa �Si i R (JL ' ADDRESS LA) F IIy1� .,rrl, �� LIC• '{ACL pHON!LIJ"1 1 Sh(r:(o�O SUB CONTRACTOR ADDRESS UCI f� Ems-PHONE��"'��`"' TYPE OF SEPTIC WORK: NEW IN87ALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WrrHIN 200 FEET OF SUILDING.1 PBIC TESTI�I 1 HOW MANY Z APgloetlon I_� 7 �p-� INSTALLATION WILL SFAVF. RESIDENCE❑ COMMERCIAL❑ OTHER❑ NUMBER OF UVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/ORFASE TRAP ElTYPE/MFO CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE �( UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.A,LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE i MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE i- SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 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 SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FORWHIC14 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 WORK 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 INS `M PECTION$. CO RA COMPLETE DRAWING BELOW. SIGNEDX j1�i c=!� TITLE! C.a iit ll.. CCCA14 GA 1 DATE: PLOT PLAN(DRAW TO SCALE)SCALE ) i� •,e I''I� 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. 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 WAIJLB. THE PROPERTY OR ADJOINING PROPERTY. Roam JL `� 7�11, #�#�Y�YQ69o1 '9 AUG 15 1996 =DETAI¢ r SAN JOAOt;ild�NPUBLIC HEALTH SERVICES _ - nor.eEI.:NVIRONMLNTAL HEALTH CIVISI_C'- DSEE .D—S�oF,E� ct*a. �`2c� 3.