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i APPLICATION FOR LIQUID WASTE PERMIT SAN,joAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PA'BOX SM 304 EAST WEBER AVENUE, STOCKTON, CA SMI-M ` 1209) 488.3420 ON•R UNDABLE P MITEX�PIRES I Y.&1.I FROM DATE ISSU P/V�'z q,(— 26-1 MIr III APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION HI MADE IN COMPIIANCE VWITTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 11 O.3 AND THE STANDAROS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OIVISYJN- c7za RSq APN► CITY �� C�6 1lN _LOT 812EAM ~ ADDRE88 0 5 _ �l GGVN ,r _ -�7 `Ll PHONE-- CONTRACTOR ADDRESS LICI PHONE BUS CONTRACTOR ADDRESS L.ICI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REvAIUADOITION ❑ DESTRUC INO SEPTIC BYBTEM PERMITTED IF PUBLlC SEWER 18 AVAILABLE WITHIN 20D FEET OF BUILDING,1 PERK TEtTtO 1 I NOW MANY AppSeoSen INSTALLATION WILL SERVE: RESIDENCE G COMMERCIAL❑ OTHER C] NUMBER OF LINO UNIT&: NUMBER OF NWROOMG! NUM&Ot OF EMPLOYEM: CHARACTER OF BOIL TO A DEPTH OF 3 FEET:` PRTISUMP SOIL CHARACTER: WATER TABLE DEPTH_ SEPTIC TANXtGREA&E TRM ❑TYPEIMFO_ CAPACITY NO.COMPARTMENTS PKG TREATMENT PLAIT❑ INSTANCE TO NEAREST: WELL FOUNDATION FRDFERTY LINE LIFT STATION❑ ain TYPE OF PUMP BAND OIL SEPARATOR 0ICLOWD SYSTEMI LEACHING LINE ❑ NO-i LENOTH OF EWES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE RLTlR EM ❑WIDTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LEWTH _DEPTH INSTANCE TO NEAREST:WELL _FOUNDATION PROPERTY LINE SEEIFAOE FIT& ❑ DEPTH 812E ,NUMBER LIN DISTANCE TO NEAREST:WELL ^FOUNDATION PROPERTY E SUMPS El WROTH LENGTH !DEPTH DISTANCE TO NEAREST:WELL_ FOUNDATION PROPERTY LINE DI&POML FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HERESY CERTIFY THAT I HAVE PREPARED THI8 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE'MTH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICEN EU AGENT'S BIONATURE CERTIREB THE FOLLOWING;'1 CEFITIFYTHAT IN THE PERFORMANCE OF THE WM714K FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO IAMRKMAN'8 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WIVOM FOR WINCH THIS PERMIT IS IBBUED,I SHALL EMPLOY PERSONS SUBJECT TO IF KMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL,24 HOURS IN ADVANCE RADII ALL R111CURED INSPECTIONS. COMPLETE DRAWWO KWW. //� J li�8 NED X TILE:. __ DATE:'— { PLOT PLAN(DRAW TO BCALM 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 OUTLINER AND LOCATION OF ALL EXISTING AND PROPOSED 6TRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON INCLUDING COVERED AREAS SUCH AS PATIOS,DNVEWAYB,AND WALKS, THE PROREIITV OII ADJOINING P1IDPERTY, . 3 3iPLC- FOR DErARTMINT USE ONLY APPLICATION ACCEPTED BY DATE: ARE&_ _ TANK,PI OR BUMP INSPECTION 8Y _ DATE I I FINAL INSPECTION 8Y ADMIONAL COMMENT8: I-f or pc.c_L4 ctN-t-t ACCOUNTING ONLY: AID/ FRCP VE CODE FEE INFO AMOUNT REMITTED C K/ ASH RECEIVED BY DATE GR 1 PERIM"N11RME11 INVOICE yZZ I OZ p�°� ? 8 oti S 217 ESQ