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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 384 304 EAST WEBER AVENUE, STOCKTON, CA 9MI.988 (209) 468.3420 �5 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR ROM DATE 1399 (�` J ICompMts In TrIplkEt+l - APPLICATION 18 HEREBY MADE TO THE SFW JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPUANCE W9T1i SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVMVJN. JOB ADDRESSIOR APNA �) i ` CITY /4 LOT SIZE OWNER'S NAME (J�.0 _ I{/Lr ADDRESS �1 - PHONE CONTRACTOR_ L u ADDRESS , /!zla uct -::I ` �P IONr SLID CONTRACTOR__ ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: VIEW INSTALLATION ❑ RETAIRJADDITION DOTRUCTION ❑ EI` FI / , (NO SEPTIC SYSTEM PERMrTTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDIN6.1 FERC TElT(O 1 1 ANY1 ' " Apglauton Jf INSTALLATION WILL SERVE: RESIDENCE TRY COMMERCIAL ❑ OTHER❑ _ NUMBER OF WINO UNITI:___/ NURSER OF (J OOO�MB �y NUMBM OF EMPLOYEES: x+'•,14 J�i,_rUi`r�;liLl(4r`r CHARACTER OF SOIL TO A DEPTH OF 9 FEET: i:� _PITAIUMP SOIL CHARACTER: WATER TABLE DEPTHc• -�UbLI �-j H jf=RKEc �'fl � yf)IVI PsT$I t r,iT $IF SEPTIC TANKFd1EASE TRAP ❑TYPEJMF6_ CAPACITY NO.CDMPARTMENiR - PKG TREATMENT PLANT❑ INSTANCE TO MEANEST: WELL FOUNDATION PROPERTY UNE 1NfT S ATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) rrao .------- T— ` LEACHING UNE ❑ NO,&LENGTH OF LINES'"" ��T 7' DISTANCE 70 NEAREST:WELLZO�F+JUNDATl MllERTY UNE a.2 FILTER BED ❑WIDTH LENGTH -DEPTH DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH 4 DEPTH DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH 812E _NUMBER DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY UNE M SUPS 13WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIME DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT TXIE WORK WILL BE DONE IN ACCORDANCE IN"SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULE; AND REGULATION8 OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT'B SIGNATURE CERTIFIER THE FOLLOWING:'I CWFIFY THAT IN THE PERFORMANCE OF THE Wo K FORWHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNEII AS TO BECOME SUBJECT TO WOPiLLMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOfK FOR WHICH THIS PERMIT 18 ISSUED,t SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE PiIR ALL REOURED INSPECTIONS- COMPLETE DRAWING BELOW. SIGNED Xa -b y'"`. TITUE: DATE c PLOT PLAN IDRAW TO SCALE)SCALE Io 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE REWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 010-ORAL SYSTEMS. 3- DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, E. LOCATION OF WELLS WITHIN RADIA OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS, THE PROPERTY OR ADJOINING PNOPERIY, - - ---mac f tv q . 1 SC ....: . .:... .. . . . 1`905PARTMENT USE ONLY APPLICATION ACCEPTL'D BY DATE: TANK,PIT OR SUMP INSPECTION BY 117 DATE I , !_•FINAL INSPECTION BY DATE ? ADDITIONAL COMMENTS: ACCOUNTING ONLY: A10+F FAC# FE CODE FEE INFO AMOUNT REMITTED CHECK#MASH RECEIVED BY DATE SR J PE WYT NUMBER INVOICE I r� 0 52p4 i