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�G-- APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES �1� ENVIRONMENTAL HEALTH DIVISION P.O.BOX 368,445 N, SAN JOAQUIN ST.,STOCKTON,CA 95201.0388 (2091 468.3420 NON-REFUNDARiE PERMIT EXPIRES 1 YEAR FROM HATE ISSUED {Complete in Triplkatol APPLICATION IS HERESY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.11 10,33 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUSLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESSIOR APN! SO �9 ( / CDY L-/�+'t.GC1Jn LOT SIZEjk�AdU� OWNER'S NAME f].k) /t '-1 AGGRESS CONTRACTOR .. ADDRESS/(U// C ® "4 Z..�jPHOP/NIOE NE�r��!✓'3 SUBCONTRACTOR ADDItE56 UC* PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION,X, RFPANVADDITION ❑ DESTRUCTION❑ IRO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET Of BUILDING.( PvIC iEt7h1�MANY �/ APPBe.tion/ INSTALLATION WILLSOM: RESIDENCE JLT�, COMMERCIAL❑ OTHER 0 NUMBER OF LIVING UNITS: ___�_��N1IMBER OF 8Eb1i00M8;_ *4 DUMBER OF EMPLOYEES: SH/�i TER OF SOIL TTS PTH O*FEIPE:Z-emz qTp SOIL CHARACTER: � J C /WATER TASK DEPTH�MENTB _ �EPTIC T�y� Y'Y'4— CAPACITY_ TREATMENT PLANT❑ DISTANCE TO NEJWEST: WELL_Z2 FOUNDATION S _ PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE NO.b LENGTH OF LINES 3/(JGl' ��/[�?.Q-, DISTANCE TO NEAREST:WELL�f��rt' FOUNOATN)N - + PIIOpERTy uNE_ .�jE10 V� } FILTER ILEO ❑WJOTH �' '�' LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE MTS PTH SIZE I NUMBER_'&i DISTANCE TO NEAREST:WELLe!-OVNOATIOIN pgOpERTy LINE C+P SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY UNE DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE \� F HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,ANO RULES ANOREGULATION6 OFTHE RAN JOAOUINCOUNTY.HOMEOWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THEWOIIK FORWHICH /( THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUEORNIA,- CONTRACTOR'S HIRNO OR 1,5 SUB-CO 81GNATURE CE EST F�IA C IFY THAT IN THE PERFORMANCE OF THE WOR(FDR WHICH 7HI5 PERMIT 19 155vFA,1 SHALL EMPLOY PERSONS SUUJECT TO WORK 'S CO NSA LA OF CALIF ANT MUST CALL 24 NOUNS FN ADVANCE FOII ALL REOVIRED iNSPEGTroNO. COMFiETE DRAWING BELOW. _ yr ` SIG ED% y y ! I � TITLE• !Ll.� DATE: �G��`—�!f- h PLOT PLAN IDRAW TO SCALE)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 DIRQCTIO", EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXWTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFT'FT.ON INCLUDING COVHiEO AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. _... .,,. .. ....: acs . . .`! CCtctn�t�u7: . '.... .. �, t �I vc w«y AYMEI NT P .. y. . wj» DCT 3 t 1911 v 1 } I- . 1 JI 5 T! ��JI il tiylP r`vI0 „ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BV DATE: AREA:` TANK,PIT OR SUMP INSPECTION BY DATE ! ! FINAL INSPECTION BV .,,�,�/>�•" DATE/L 1=-1-9Y ADDITIONAL COMMENTS: � - ACCOUNTING ONLY: AIDE FACE n PE CODE FEE INFO AMOUNT REMITTED C EC tC ASH RECEIVED BY OATS SR!PERMIT NUMBER INVOICE E Z (0' •