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f I ` sS'PPLICATION FOR LIQUIfI WASTE PERMIT , r SAk—,*3AOUIN COUNT,PUBLIC HEALTH SE CES ! , ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 9520 (209)458-3420 �� ,/�� N•REFIINQABLE PERMIT EXPIRES I YEAR FRQAf DATE 135UEQ ._,�;.' 1,+� '� I J ICompMt�in 7rsplieat+ti f APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN l JOAQUIN COUNTY DEVELOPMENT iTITLE,CHAPTER 8-1/110.3 AND THE STANDARDS�OF SAN JOAQUIN JOAQUIN COUNTY PUBLIC HEALTH SERVICEB.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# S l AO —1 1t-Ii�/� V� W�Sf/r�/��7/ � CITY /�f� [�( LOT SIZE / ryL IL� / OWNER'S NAME �.t �i. W\\Y�LV• � ' ADDRESS �k11' L`I_I ',��►A/l.J I.OIC.�Q��f[(/) e j'r ` 3 X l RHONE ao� `'E 63- -6 ob i CONTRACTOR �\V• Y7 AODRES>;,r�L/,J�I lust ` � �S�'' L- N PHONE Lel SUB CONTRACTOR ADDRESS UC# RHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADbITNON ❑ DFJITRUCTION❑ (NO SEPTIC SYSTEM PERMITTED 1F PUBLIC SEWER 1S AVAILABLE WITHIN 200 FEET OF BUILDING.) pBRC TESTI+1 1 I HOW MANY INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALS OTHER ❑ ' NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITIBUMP SOIL CHARACTER: WATER TABLE DEPTH 4p'. SEPTIC TANKIOREASE TRAP ❑TYPEIMF6 CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELLFOUNDATION PROPERTY LINE UFT STATION❑ 61ZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) i LEACHING LINE ❑ NO.h LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE F FILTER BED ❑WIDTH LENGTH OEPrH 01STANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE Jl{ SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE l DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE f I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOFRK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINAHCEB AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I 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 HIRING OR SUIT-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM P S8\A`JTI10NL]A(W�S{�OF CALIFORNIA.' THE APPLICANT MUST CALL 24 FOURS IN ADVANCE FOR ALL 'RECUIREDD INSPECTIONS, COMPLETE DRAWING �BELOW. SIGNED x� l�Y-/ `�"Cl�ly� - - --TITLE: VCv O 1 I 00 DC. DATE-L_J 'C�O PLOT PLAN(DRAW TO SCALE)SCALE_, L. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE C49 DM IIYBTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE OISPOBAL SYSTEMS. 3. DIMENSIONED OUrUNES AND LOCATION OF ALL EXIBTINO AND PROPOSED STRUCTURES, G. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. L- - - . .. ....... . ` .. ....... ... _- e 2 I , -..-.--.....i.......... ...........r... .,.. - ._. _.. . .. ._.� ..__,.- .. - .. ............— — .. ..... - - - P.�f .. ifs ue ...... N -- — -- ... ... ... ...... . ,r� , .... ... :. .. .. ... .. C� : � Ike V � I r.. t r�� ^ �} . .. .. .............................. EN .. A . _ _ N J Lew FERC TEST AND SOIL BORING ...... I .1. 64 I : .,..... .... .. .. . .r, ?UII�i 6 � :A�-.IUFs lJ1VY`f IL H r.ICE S c i...... :;i BRANDT ROAD 300 FEET WEST OF HYW 88 LOCKFORD FOR DEPARTM T-USF. o rPLICATION ACCEPTED SY~ V C DATE: `•' AREA: ANC,RT OR SUMP INSPECTION BY OATE��(�^FINAL INSPECTION BY ->�/1// yS i' DATE rl4 r DDJTIONAL COMMENTS: ,dY l ��i �� '>' ✓ • �' _ A' '"' 'FC„ UYJe1.1 ACCOUNTING ONLY: AID# FAC# - PE CODE FEE INFO AMOUNT REMITTED NEC (CASH RECEIVED BY DATE BR I PERMIT fLU1N1r9t INVOICE Pub.Heetth Serv.-ErnriTO,174(3/96)