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L i APPLICATION FOR LIQUID WASTE PERMIT } _ 3 SAN'JDAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PP,O,BOX SSS,304 EAST WEBER AVENUE,STOCKTON,CA 9SMI1 S(2091469.3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 1SSUED (Complete in TTipfieAfel APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIF!COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11110,',{AND THE STANDARDS OF SAN JOAOVIN COUNTY PUBLIC HEARTH SERVICED,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSOR APNN 7 /J-Z C:7 - C..,yg 'Qi L�u:FL tfTY '` r / . .... LOT slzE//�licw'i OWNER'S NAMEyGfTT�/fIT//riT �j�,/r/[ ADDRESS �l-` 9 �// PHONE FLONTRACTOR 'C(S� !�'. .'� ADDRESS_IZI 57Cfrt-RL "It/s� [.- LIC/ J7 VV22-` PHONER.�F' BUD CONTRACTOR ADDRESS UCN PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ bEATRUCTIOM❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER ISA AILABLE WITHIN 200 FEET OF BUILDING-1 11 � PRBC TEAYIO f I HOW MANY '}.{ w fL B/ dG✓e' [/+�/� APdlaelien I Fl.11TALLATI......: RESIDENCE❑ COMMERCIAL SJ OTHER 0 'C; NUMVER OF LIVING UMTS: NUMBEII OFrBEDROOMS: NUMBER OF BMI;": rC+ ✓e'. C OF 601E TO A DEPTH pFI�7I FEET: c! PR/SUMP SOI!CHARACTER: WATER TABLE DEPTH EEmC TA EA6E TR1A-yP LJ TYFE/MFG ,L - ct t; CAPACITY ,f '�'�f .-}7 I�"%� Nd.C01.GPARTMENTB -A PATMIOT PLANT❑ MOTANCE TO NEAREST: WELL[�.Y." - FOUNDATION ;J t L PROPERTY UNE UFT STATION O��S92E TYPE OF PUMP SAND OIL SEPARATOR IENCLoSEb SYST'E"MIS LEAcWNO UNE g-NO.6 LENGTH OF UNEB -'/✓ev! / DISTANCE TO NEAREST:WEupRPLr FOUNDATION 75 PROPERTY UNE J✓ F ETERGED /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNEOUNDEB \13 V'ADTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION r�� PROPERTY UNEIOIAOE NTA J�J UEPTH_��j SITE �i NUMBER,.,S DISTANCE TO NEAREGT;WEL✓,SU t FOUNDATION-260 PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE p06POSAL PON BA ❑WIDTH LEN6TH DEPTH DISTANCE TO NFAREST:WELL FOUNDATION PROPERTY UNE 4 w. 4 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COVWY ORDINANCES AND STATE LAWS,AND RULES UID REGULATIONS OFTHE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AOENT'S SIONATURE CERTIPEB THE FOLLOWING:'I CERTIFYTHAT IN THE PERFOPIMA NCEOF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOME SUBJECT TD WORKMAN'S COMPENSATION LAWS OF CAUFORMA.' CONTRACTOR'S HIRING OR I SUB-CONT NATURE CERTIFIES THE WING:'1 CERTI THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TRIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOFKM `8 COMPEN ORNIA.' HE APPUC T UST CALL 2e PIO[AS IN ADVANCE FOR ALL REQUIRED INSPECTION!. COMPLETE DRAWING BELOW. c { F'413-113 TITLE!�- DATE /I19""06 ROT PLAN(DRAW TO SCALEI SCALE -to T.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED :.OUTLINE OF THE,PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. #.MMENBIONEb OUTLINES AND LOCATION OF ALL EXIOTMO AND PROPOSED STI�VCTVREA, 6. LOCATION OF WELLS VJITHIN RADIUS OF ONE HUNDREo FIFTY FT.ON INCLLIDINO COVERED AREAS SUCH AS PAPOe,DRIVEWAYS,AND WAUCS. — THE PROPERTY OR ADJOINING PROPERTY. I,. ... ` ydA,5c A. I r L L� q ... �L N ' ArIIGS 1a7a > It ... 1. r ,J.:.- 9Fr , 1 ri r cl1 s : .. .. .. I• _. '. F _. ........ ....,. .,,,.. FOR buAATM6NT LIKE ONLY WCATION ACCEPTED BY DATE: �y Zj t `� _ AREA:�-� TANK,PIT OR BUMP INSPECTION BY DATE I I FINAL INSPECTION BY J/.�c(/ I DATE 0IT1ONAL COMMENTS --------------------------- ACCOVNTNO aNLY: AID/ FACN f'E CODE FEE INFO AMOUNT REMITTED CHECKNICAsH RECoVED DY OAT9 SA I PERMITNUMBER INVOICE I 33 C' (oh— Q-22, ~L --