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P APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 380,446 N. SAN JOAQUIN ST„STOCKTON,CA S5201-0388 (209)468.3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Conopi.ti in Troil"u) APPLICATION IS HERESY MADE TO THE SAN JOADUIN COUNTY FOR A PERMIT TO CON8TRLJCT AND.OR METAL].THE W DW DESCRIBED. THIS APMJCATIDN IS MADE IN CCYPIJANCE'WITH BAN JOAQUIN CUUNTY DEVElOPM�E"7HT TITLE,CHAPTER -9--1 1111 00.3�AND THE STA.NDARD3 OF SAN JOAOUIN COUNTY PUBLIC HEALTH S.E�R-V�IICES,E/NTVIRONMENTAL HEALTH DIVISION. JOB ADORESSK;R ARIM�/J.t/y� ly 1 / /F�r,,��/ ~� i-•'J - OWNEWO NAME��G�/�/ /v �Q�Z_�J T� -ADDRESS / / LOi 512E �) � PHDNE�/�/CONTRACTOR i� �/ y C, ADDRESS SUB CONTRACTOR -ADDRESS ADDRESS LTC/ A—, TYPE OF SFPiIC WORK: NEW INSTALUTIOR❑ RtaASRIAppT1ON D[ATRUCTION❑ WO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABIE WITHIN 200 FEET OF BUILDING.] P91C TFATUI I)NOW MANY E.f APp1iGAKon ILL ✓/_ INSTALLATION W SERVE: RESIDENCE IEI COMMERCIAL❑ OTHER❑ NLAMAER DP UVINO UNY.. NtMB/ER OF BEDROOMS,: NU MIXER OF EMPLOYERS. GHARI1CTEi{OF 60K TO A DEPTH OF 3 Ff iT:�'L q f+1T(eUMP 691E CMMACTkR: WATER TMtF pEPfH �,7r SEPDD TANK/OREASF TRAP ❑TVPEMFG CAPACITY NO.COMPARTMENTS PKD TREATMDIT PLANT❑ DISTANCE TO NFAREAT. WELL FOUNDATION ROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) L _ �N � EACHIND LINE HO.S LENGTH C'OF LINES I DISTANCE TO NEAREST:i�EiE �-PROpERTV UNE_��L FILTER SAID ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELT. FOUWATION mo ERrY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE `T bEEPAOE WTS �OEPTH 512E- A�J`NUMB __/ DISTANCE TO NEAREST:WELL2�FOUNDATION 9�• PROPERTY LINE—� SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE C DISPOSAL PONDS ❑WIDTH LENGTH _DEPTH DISTANCE TO WARIEST:WELL _FOUNDATN)N FIIDIERTY LINE 1 HEREEIY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORN WILL BE HONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RL;M AND REGULATIONS OF THE SAN JOAQUIN COUNTY-HOME OWNER OR UC.ENSED AGENT'S SIGNATURE CERTIFIES THE FOUQ W HG:'I CERTIFYTHAT IN THE PEIFORMANCE OFTHE WORK FOR WHWH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WKIIKMAN'S COMPENSATION LAWS OF CALIFOPWA_-CONTRACTOR'S MOWS OR SU6CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY TiAT IN THE PERFORMANCE OF THE WORK FOR'WHICH THIS PERMIT I8 188UED,I SMALL EMPLOY PERSONS SUBJECT TO WOPKMAN'8 COMPENSATION LAWS Of CMIFO�.- THE AFAUCANT MWT CALL] MOURS IN ADVANCE FOR ALL nFOUI RED INSPECTIONS. COMPLETE DRAWING BELOW. MINED }T�_ _//I/L-)/ TITLE:\' /��'Q_"+Kl DATE: "VVV rrr q OT PLAN/ID`RAW TO SCAL.)SCALE _ IA 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. A.IACATION OF HOUSE SEWAGA DISPOSAL SYSTEM OR FFOPOBED 2.OUTLINE OF THE PROPERTY,WITH OIMENSMNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURzf, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AHFAS SUCH AS PATIOS,OFIVEWAYS,AND WNXS. THE PROPERTY OR ADJ04NMG PROPERTY- .. _ I .. :. .....,.. ... .,fir, "•mom—fi4• R • - � b. :.. . - I D :f . n_ 7 _ POOMIE i [. 1 - — l� I' A Dot -7— w fA{�J(/ — ... ...:........:....D III — -i AL:H�jgC • I f — -- -- E'k�r�tlN�rt.A7 �-Ff4'I r :V.A.PARft4SH 8 NS PIO =j' j" i' fS!'(Jn R POST ORgDE DO REPO . 9:OCKTUN,E:AufOO at y;]01: i . i •t_710}MB6ST10!+3b-4S F"*10.n a FOR DEPARTMENT UAE ONLY ' •_ 6 R 4�� +15 1 APPLICATION ACCEPTED BY C'�`' l'� DATE: �'•'L��-�r>F� AREA; ` 1 TAN(.AT OR SUMP INSPf./ BY DATE / / FINAL INSPECTION SY 4ATE S f]^ ADDITIONAL COMMENTS; S- ACCOUNTING ONLY: AIOM FACT PE CODE FEF INFO AMOUNT IRB.RI-Tm C KS ASK RECFNED AY PATE W!PEPMi.—ER INVOICE I fi 2 � D