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rr APPLICATION FOR LIQUID WASTE PERMIT f l� SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 i (209) 468-3420 NDWREFUNDAREE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CarpIBEU II TripliFln) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT MWOK INSTALL THE WORK DESCRIBED. THIS APPLICATION M MADE IN COMPLIANCE WTTII SAN JOAQUIN COUNTY DEVEIDPMENT TELE, CHAPTER B-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JDB ADoREBS1oR APNJ L4� � � 'S . 'V73' �i1. ,4 V lk �I _ GTY �j�/J�/ C ii - Lo 3SIZE S �X ' OWNER'S NAME _/r: /►)F4 ADOREss_$�.�_�ZrL,D SOL .2./� 9.(.�SSISF PIwNE S//J-?/Lsl :r�� CONiRACTOFI /ij�..c/v5)/T S ADORESII: l IV' Wtf soA/ LL,'/¢y _ucc�*^w!= ; P10NE_ SUBCONTRACTOR _ f/ l/�}'. '% ADDRESS UC! PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPIUR/ADOITON it OUTRUCTON ❑ INC SEPTIC SYSTEM PEiUNDTED IF PUBLIC SEWER 16 AVAILABLE WTTISN 200 FEET OF BUILDING.) PBRC TFSTIII ( I NOW MANY �,y Applo . D INSTALLATION WILL SERVE: RESIDENCE T` COMMERCIAL ❑ OTHER ❑ NUMSEI OF LIVING UNITS: j NUMBER OF SEDROOMS: / NISLfER OF YAKOYMS CHARACTER OF SOIL TO A DEPTH O,FF33 FEET:.4 �g� PTfbUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASB TRAP E}0Sy TYPE.MFG CAPACITY NO. COMPARTMENTS PKO TREATMENT PUA1�N1T1 13 DISTANCE TO NEARTAT: WELL FOUNDATION MWPERTY UNE LFT STATION LJ SIZE TYPE OF PUMP SAND OIL SEPARATOR (ENCLOSED SYSTEM LEACHING UNE NO, A LENGTH OF LINES ,C}/VE /]r%� DISTANCE TO NEAREST: WELL &d2Q(ig-F FOUNDATION PROPERTY LINE_ FILTER SED ❑ WROTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE MOUNDED R❑R77II WIDTH LENGTH�A. DEPrH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE SEEPAGE PITS Iq DEPTH SPIE ^Y.'7" NUMBER — DISTANCE TO NEAREST: WELL/1I/'NEFOUNDATION-� PROPERTY ONE �lJ� SUMPS ❑ WIDTH LENGTH DEPTH DISTANCE TO NEARIEBT: WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑ WIDTH LENGTH OEPTH DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE 1 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 TNG SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: *1 CERTIFY THAT INTHE PERFORMANCE OF THE WORK FOR WINCH THIS PERMIT 18189UED, I 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 WOTPL FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAJLIF,O�l`N�If\A' THF APPLICANT/MUST CALL u HOURS IN ADVANCE Fp1�— REyIG-ED M/SPECTIONS. COMPETE DRAWIN/G'B+ELOW. 81GNED,Y J. ✓. �! :, 1) C --9-'C TITLE: Y__J/ ' ' DATE: O — PLAT PLAN IDMW TO SCALTI SCALE 7. 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 DISP06AL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROMSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON INCLUDING COVERED AREAS SUCH AS PATIOS, f) _ PHOPCRTY- FOR DEPARTMENT ULE ONLY APPLICATION ACCEPTED BY DATE:, TAW, PIT OR SUMP INSPECTION BY GATE J I FINAL INSPECTION ADDITIONAL COMMENTS: U' AREA: C) OATS -�1 '-'C� I� G �tJ I 71f� 6 E I 1Z D, I �A.r- p ED LEI z o v) Lj 0 I`I LL! QJ C'2� :O .....-L 1 U - W �ja :s a z AREA: C) OATS -�1 '-'C� �A.r-