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APPLICATION FOR LIQUID WASTE PERMIT " SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION j �\ P.O.BOX 388,445 N.SAN JOAQUIN ST., STOCKTON,CA 95201.0388 (209)488.3420 NON-REFUNDABLE PERMrr EXPIRES 1 YEAR FROM BAT ISE SUED ICBInplsa in Trpliaan) APPLICATION 19 HEREBY MADE TO THE BAN JOAOUTN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WRH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OMSION. JOB ADDRESS/OR APNF /0/ C c I, CRY_ � /":'- LOT WE W ONER'S NAMEI. AD�DRESS ` rn C PH4�3 1/ I S�D CONTRACTOR K�G01�r77� )) O H r,Y�OLWRE98 � ' //lel rd(� 11CIJ.��3 5 PHONE�3,L/ SUB CONTRACTOR �..� ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ RpARVADDITION DEATRUCT10N❑ MO SEPTIC SYSTEM PERMITTED F PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.I PEW TBTHI I I NOW MANY Ap11ISABwI P INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL 90 OTHER❑ NUMBER OF LIVING UMTS:-- NUMBER OF BTEEDRO/OMSS�: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: lJ rf tom.L=-- NTMUMP SOIL CHARACTER:0-1'j Pnj WATER TABLE DEPTH SEPTIC TANK/ORFASE TRAP ❑TYPE/MFG— CAPACT-Y NO.COMPARTMENTS FKO TREATMENT RANT D DISTANCE TO NEAREST: WELL_uQ� FOUNDATION OO PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP SANG OIL SEPARATOR(ENCLOSED SYSTEMI / �j / y LEACHING LIME 13 No.4 LENGTH OF ONES(122 t DISTANCE TO NEAREST:W�L FOUNDATION LINE i FILTER RED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE - MOUNDED ❑WIDTH ` LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH_J-SRE�NUMBER1_DISTANCE TO NEAREST:WELL.20"Y'l FOUNDATION �PROPERTY LINE �( SUMS ❑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 I/LAVE PREPARED THIS APPLICATION AND THAT THE WORK TALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY,HOME OVINEROR LICENSED AGENT'S SIGNATURECERITHES THE FOLLOWING:'I CEKTFYTHAT INTHEPERFORMANCE OF THEWONK FORWHICH .ter THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOFKMAN'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 PEi1Mff IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNI THE ANT MUST CALL 24 HOURS IN ADVANCE FOR /AU ALL FEORED INSPECTIONS. COMPLETE DRAWING BELOW. �/•/,` [� SI TITLE: \ C _DATE: /014q T llg.W TO SCALEI SCALE -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR R&h4bING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE D48POSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL By EMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6.LOCATION OF WELLS WTfHN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERLY OR ADJOINING PROPERTY - See k31 Rln� a55 � :_...... .. .. .... .... .. .... .. :. ... _ ..4..... .. .... .... ... - �• Owl (�1 • , (� u w EAFv s . . . pL PAYAo� NT A,�# b/LLeDIY; AEG'�INED i994 Tm _ .PUBLIC NE2104 7 l I S�c�<u. - Pnjeci I A\ FOR DEPARTMENT USE ONLY eA APPLICATION ACCEPTED BY C •, l' DATE: Z AREA: ��/ TANK.PIT OR SUMP INSPECTION BY t<•N�� '1/1145 F' DATE l I FNAL INSPECTION BV DATE 1/`✓ 1 L ADOITIONAL COMMENTS: - �l ACCOUNTING ONLY: AIUF FAC,F �, Il�ll/•' S /x s/ 3�Ln�I" .S C. PE CODE FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE SR/PBPA/IT NUMBER INVOICE/ 5-13D S 049 Cs� -