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r APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 389, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-0381 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED IGmpl{u in TT4DE{u) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CON97RUCT AND/OR INSTAL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPUANCE WTTH SAN JOAQUIN COUNTY DEVELOPMIENT TITLE, CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISK)N. JOB ADDMESS,'Oh APNO 1Y 0 � 1 (L E' Rcxy 1A e V( �, (CA 0 -.- / yy n.. CITY II O f� <- I `� �fL/df Q&ZE SDb L) OWNER'6 NAME J o ,,x LA V `� LI �r ADDRESS ES V1 f Ef NK V h C� P� TTL. PHONE %Lp I ^ 0130 - I COFfTRACTOH Vv V' 6 S �, If 5" t, ADDRESS 9590 N, , wA.,E LK:/ 25'1`313 FHOY,E SUBCONTRACTOR ADDRESS UCS M40HE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REFAIKALU I N DUTRUCTION ❑ (NO SLPfIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILINNO.I I .. TE•THI I I RPW MANY AFWoASoR I INSTALLATION WILL SERVE: RESIDENCE T COMMERCIAL d DTHEH ❑ NUMBER OF UVINO UNITS: ON F; NU�AiB1 O,/F�YED1100M{: � NUMBER OF EMPLOYEil: It CHARACTER OF SOIL TO A DEPTH OF 3 FEE.'' M _L� "LE 5 %T/SUMP SOIL CHARACTER: �E WATER TABLE DEPTH��2 SEPTC TANKIOREA6E TRAP fI TYPE.T/FG /9 Y 4-� CAPACITY I lou _ NO. CDMPARTMENTS PKO TREATMENT PLAIEN�ryryT 0INSTANCE TO NEAAEIIT. WELL FOUNDATION PROPERTY LINE UFT STATION U S17C TYK- OF SA1N-D OIL SEPARATOR (ENCLOSED SYS'TEMI //�� L j 1 LEACHNO UNE Nc NO. 8 LENGTH OF LINES_ 1 4L DISTANCE TO NEAREST: WELL FOUNDATION_L22_—PERTY UNE FILTER EED Q WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE MOUNDED ❑ WIDTH LENGTH_ DEPTH DISTANCE TD NEAREST: WELL FOUNDATION PROPERTY UNE SEEPAGE FITS DEPTH z .`] SIZE y E NUMBER % LL DISTANCE TO NEAREST: WEFOLINDATN]N PROPERTY UNE SNAPS ❑ mw H_ _ LENGTHDEPTH OISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE DISPOSAL POND{ ❑ WIDTH LENGTH-- OEPTH DISTANCE TO NEAREST: WELL__ FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TEAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LWENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING: '1 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 CALIFORNIA.' CONTRACTOR'S WRING OR SUB CONTRACT ING 5 NATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 USUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CD N TION LAWS OF CALIFORNI THE APPLICANT MUGT CALL N HON16 IN ADVANCE F044AU REQUIRED INSPECTIONS. COMPLETE DRILWJINO BELOW - SIGNED X Y`^ TITLE:_ � " � DATE' ROT RAN (DRAW TO SCAIFI SCALE--' 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2OUTLINE OF THE PROPERTY, WITH DIMFN6 N8 ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 7 DIMENSIONfO OERLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. 6. LOCATION OF WALLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON INCLUDNNO COVERED AREAS SUCH AS PATIOS, DRIVEWAYS. AND WALKS a THE PROPERTY OR ADJOINING PROPERTY. a+t 4 r'Y acE E.1 1 o � a S`I New S r� -! I� i'eE vR�G �CL.YICtS �a 1'x 00 C 0010 VMS 0 50i F �o w ell 11 nn o HIYIN CQ J, AloQInpnnOiA 1<ill-Qrw-r, L wa 5c,p�;� Cc,tik. PAYMENT $Z RECEIVED APR 281995 SAN JOAQUIN GGUN''e l+ ENVIR0 `M- TAL EALTH DIVISION 0.'k Gk�Y tiL� �+` (I /E--�� .. �_, FOA DEPARTMENT LYE ONLY APPLICATION ACCEPTED B. c 5& �+T" GATE: V7J TANK. IIT UR SUMP INSPECTION RV DATE ! FINAL SPE MON BY ADDITIONAL COMMENTS5. I Z ACCOUNTING ONLY. I AID' I FACE AREA'. c1 DATE rD 11 L I 1 -I- II11 PECGDE I FEE INFO I AMOyNT REMITTED I MEC !CASH I RECEIVED BY I DATE I M ! mmMvr NUMBER I INVOICE F II 1 m