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APPLICATION FOR LIQUID WASTE PERMIT — SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,446 N, SAN JOAQUIN ST.,STOCKTON,CA 9620E-0389 (209)458-3420 MON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICo1BPIMa in TF*IieTB) APPLKATI.�N IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMA INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLJANGE I:GTTH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 .3 AND THE STANDARDS OF SAN JOAGUINCOUNTY PUBLIC HEALTH BE E6,ENNARONMEEJNT/A•L HEALTH DIVISION. JOB ADDPEBSA:R APNF /, �. L CITY l-` ,T 7 Z 7 -T� LOT SIZE OWNER'S NAME$ AppAE58 ^^ /7� �!r L+>�.V /pHpNE�ry_ z- CONTRACTOR - — L L? ADDRESS�LLG {.>.t}' 1 1 - (..S Z�/LOCI 7-z4 PFpM _ SUB CONTRACTOR_ ADDRESS UGI PONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ RtDAI N ❑ DFJ)TRRKnON❑ INC SEPTIC SYSTEM PERMITTED K PURLIC SEWER 16 AVAILABLE WITHIN 2M FEET OF BVILDING.I FWC TSSTILI I I HO-MANY �/ AppNmBon!_ , INSTALLATION MULL SSIREFACICNCE YC COMMERCIAL❑ OTHER❑ �Z{' NUMBDIOFLI I%G UMTB: �11 NLw/SII OF Bm""M//��OW/:�__NUNSFR OF WAPLCYEES. CNARALTER OF SOK TO A DEPTH OF 7 FF3T: N1'6UMP SOR CHARACTER: WATER TABLE DEPTH he SEPTIC TANIUGPEASE TRAP ❑TYPEAIFG CAPACITY NO.CDMPARTMVNTS PKD TRFATMBPT RAW❑ DISTANCE TO NLI WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF P+U]MP SAND OIL SEPARATOR IENCLOSED SYSTEMI _ LEACHING LAME X NO.i LENGTH OF UNEP rE � ICO I�DISTANCE TO NEAREST;WELL SC� FOUNDATION j I PROPERTY UNE 7 FILTER BED ❑LARDTH LENGTH DEPTH DISTANCE TO NEAREST:WILL FOUNDATION PROPERTY UNE MOUNDED ❑WIOTH LENGTH_ DEPTH DISTANCE TO NFMIEST:WELL FOUNDATION PROPERTY UNE SEEPAGE ATS ❑DEPTH S¢ENUMBER DISTANCE TO NEAREST:WELL MUNDATION —PETTY LINE SUMPS ❑WIDTH LENGTH__DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEATEST:WELL •FOUNDATION PROPERTY UNE N HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WTTH SAN JOAQUIN COUNTY ORDINANCES ANO STATE LAWS,AND RULES ANDREGU I IONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR UCENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWiNG:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THOS PEF"T IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WDRIK—G COMPENSATION LAWS LAWS OF CAUMPINIA.- CONTRACTOR'S HIRING OR SUB{ONTMCTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY TOAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUELIECT TO WORKMAN'S COMPENSATION LAWS OOFF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL HEOUIREO INSPECTIONS. COMPLETE DRAWRIO BELOW.. Q SIGNED X 41 R N y` !" TITLE:_ PATE; ^II /A PL PUN(DRAW TO SCti EI SCALE 'la H- 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, •. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,1VITH OWENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED STREKTUPES, 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY INCLUDING COVERED AF—B SIKH A6 PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY- A/r V .__.........4.. .,az.......... . ..... .. .... ... . ... k .`I .. .. .: ., F _ I �. ... ..... ............ +1Ef� ��. SAI.......... . 8 .199 .. ..........t....... .. .. .... iPJVtF��!pl NT 'rIJl:.'E - • k lit:.-i l'H j}llnGr••; FOR—ARTMENT WE ONLY AFPUCATION ACCEPTED BY V GATE: NKAREA: TA ,PT IOTO OR SUMP INSPECTION BY DATE / I NAL INSPECTION B G OA 7E Of FJO N f S ADDITIONAL COMMENTS: wCCOUNTNO OMLV: AIRF FACT PE COLE FEE INFO AMOUNT REMITTED NEC ICA" RECEIVED BY DATE OR I PERMIT NUM199R INVOICE I