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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,445 N.SAN JOAOUIN ST.,STOCKTON,-CA 96205.0388 (209)4683420 - NONAEFUNOAOEE PERMIT EXPIRES 1 YFAR FRDM DATE ISSUED ICGmpIBu in 7rpliuul APPLICATION IS HEREBY MADE TO THE SAN JOAQUM COUNTY FOR A PERMIT TO CONSTRUCT ANUMH INSTALL THE WORK DEW WRED-THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTERS-1 110,3 AND THE STANDARDSOFSAN Ja AGUIN COUNTY PUBLIC HEALTH SERVICES,•.ENVIRLONMENTAL HEALTH DIVISION. / y JOB ADDRESBJOR ApNN{Z�3� L ; r7i��^ //� 6rl U ter'L� ,[ CNY J`Q[ �O i^ ^`LOT$12E L l `` OWNER'S NAME/--q Dy��iQ�f/d�/�/�d4a, A,'e ADDRESS 77-7249- Gd'�"/s/+y'+^�� rjgC C PHONE COM ACTOR_A�.- a-o_ �rorr �TdaooPFss /6 T� CEO -r—� !�� 6/F-rrr•-n rT.c�' ---vcN y/6�3 PHONE 4�6 3-�a 7� SUEZ 0WRACTOR ADDRESS LIC# PHONE TYPE DF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION ❑ DESTRUCTION❑ [NO SEPTIC SYSTEM PERMITTED[F PUBLICSEWERIS AVAILABLE WITHIN 2OO FEET OF BUILORIG.I / Tr P9iC TE57IN[i HOW MANY >�� p,.krs7 d r�� T6 TtiS !!'af L10 (�� APPlutlon■ N INSTALLATION WILL SEINE: REEDENCE❑ COMMERCIAL❑ OTHER❑ NUMBER OF LANG UNITS; NUMBm OF BEDROOMS: NUMBER OF EmPLOYEEB: CHARACTER OF SOIL TO A DEPTH OF+311 FEET; RTI6UMP SOIL CHARALrER: WATER TABLE DEPTH SOP TIC TANKJDREASE TRAP LJ TYPVMFG CAPACTEV NO.COMPARTMENTS PKO TREATMENT PLA IT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE yLr,: LIFT STATIGN❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR{ENCLOSED SYSTEM] L,a LEACHING LINE E3 NO,A LENGTH OF LINES p1STANCE TO NEAREST;WEiI FOUNDATION FROPEFTTY UNE FILTER HBO ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDEDC]WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE E SEEPAGE RTS 1U DEPTH SIZE NUMBER DISTANCE TO NEAREST;WELL FOUNDATION PROPEKTY ONE J`L *UMP* ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERLY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH; DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY ONE I HEREBY CERTIFY THAT I HAVE PREPAWD THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNT'ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OFTHESAN JOAQUIN COUNTY.HOMEOWNERORUCENSEDAGENT'SSIGH4TURE CERT IFIESTHEFOLLDWINO;'f CERTIFY THAT IN THE PERFORMANCEOFTIIEWOW FOFI HICIA [� 8 THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOnKMAN'6 COMPENSATION LAWS OF CALIFORNIA.' COMRACTOP'S HARING OR J" SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLLIWING"I CEPTIFYTHAT IN THE PERFORMANCE OF THE WOM FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPE NSA T ION LAWS OF CALIFORNIA,'THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGRARE]INSPECTIONS, COMPLETE DRAWING�BJELOWJ.p p.C SIGNED TrrLE: OZ✓—" ZL�` I` DATE: G -LO f ROT PLAN!(DRAW TO SCALE]SCALE [o Z�1�I 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 OUTLINES AND LOCATICN OF ALL EXISTING AND PROPOSED STRUCTUFK;S. - E.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVEWTJ AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY- ... - -- .. ... . .. - .. - y ` _ ,. ..... m .... ..... ................. i" Tl� l -'' NeW ... syr.. p-I ee .... ...v ... -- ,.. jVz „ sacra ... �.� 4 .......... n ..... PAYfET ! :... :: . .... FES 2 $ SAN RAI�Ill 1 €NVIRptMENTAL H ��T'u, or} C�tt FOR DEPARTMENT UEE ONLYli ] APPLICAT]ON ACCEPEED BY L. DATE: Z .� AREA_ f I TANK.PU OR BUMP INSPECTION BY DATE I J FINAL INSPECTION -ATEA ADDITIONAL COMMENTS . /r f': T,,1y 6Q. kel - J r ,•1�z-5 Fj ACCOUNTING ONLY: AIRY FAC# l-L-' I PECODE FEE INFO AMOUNT REMIT? CHECK#CASH REC9upBY DATE OR I PERMIT NUMBER ' INVOICE# j -7g � f , a [Y