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YMEN APPLICATION FOR LIQUID WASTE PERMh REc- SAN'JOAaUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 = MS=oO—Id SAN�OA�UIN�'G (209) 488.3420 V CES p'3wCHEF�IHEP�6U)VISISP: NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N\ARkW#'6" (Compote in Triplicate) A ICATION IB 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 STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. fY1 PCT:;,A JOB ADDRESS/OR APNN_2-C>4 j 3 STPZ t=. L C�K-yv AY' i PN: Ln j�QF�'G� r' (' LOT SIZE 2S Ar. 2-C 71Esc,1 n C RS> C,N OWNER'S NAME tLLtjIN t4,PV-CQ E Y RA, T--'l l?Y, ADDRESS 'Z C')413 t�T A-1tc wAV 1207 14 PHONE�� ^,~ CONTRACTOR 4VA��I:P ADDRESS IAA-M- PLAZA ` C L7 t-�n F- '4";L W2 LIC# PHONE -'-ISI C;VINC:, IIvE SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ ,,4%L. Sli1Tf�Eil1�1'f 1 (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTS I I HOW MANY Applloatlon ��pppppplllI INSTALLATION WILL SERVE: RESIDENC E� COMMERCIAL ❑ OTHER ❑ NLIM13ER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: nG':r.�ti tt �i`4r nll'Il'I At F'�1�nl NG I i 3L"r CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PLT/SUMP SOIL CHARACTER: WATER TABLE DEPTH / I A SEPTIC TANK/OREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS FA P-EL" PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.&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 LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS 11WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 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 THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- 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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF C�IALIFO�R-N-IA�.''THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED / '., _ .f�'� - / ,�.�."i/.-�/.�.: TITLE: Ci Vji _ DATE: 4"-(,tM"ICJ!� PLOT PLAN(DRAW 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. 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 WALKS. THE PROPERTY OR ADJOINING PROPERTY. ;......i......J.......i... .........:..... aw.r . . . ... . IO PROPOSCO MRG/Kk rASIVIW .......... ............. ........ 9 L67I % g GRROa ION RW AITS i Fw 5 1 a 4 r a o Y N :T AN V A g C� VAN ALLEN ROAD cin D m �I rA FORZE T USE ONLY I l APPLICATION ACCEPTED BY �/ V" �L/�J � DATE: EA: C _ TANK,PIT OR SUMP INSPECTION BY DATE I / FINAL INSPECTION BY DATE / 1 7 IaJ ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT RWITTED CHECK#/ ASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE# 44-1v 2 3