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'4 APPLICATION FOR'LIQtrIt1 WASTE PERMIT �""� SEPTIC SANJOAOUIN COUNTY PUBLIC HEALTH St-.,VICES ENVIRONMENTAL HEA 51r !BF PT IC 304 EAST WEBER AEN,UE, SEmir (20.9).46,8-3420 NDN-REFUNDABLE PERMIT EXPIRES f 1XEAR FgOM D�j#!$S,$PL�:�AL PERFAM lcompme)B Triplke%). APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED, TH16 APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TIITLF-CHAPTER 9.1110.3 AND THE STANDARDS OF GAN JOAQUIN COUNTY PUBLIC HEALTH SS�1ERVVICCES..EWROONNMENTAL HEALTH DIVISION. JOB ADDRESSOR A/PN/vI/,/ / , e) /�/ �[/•_ 4 �. _CITY ! "�G�"�TJ(J _LOTT siz. OWNER'S NAME,/�/�/�/�/V'©4�/27X 1V�_�4 %/1 ADDRESS or+� �/,.,`,f' u�t /I PHONE / �Z[O 3�[„�J CONTRACTOR! "i�T6� .J`�� •^��-• ADDRESS Gam* che"'cll tt , L1CR PHONE G SUB CONTRACTOR ADDRESS LIC# RHONE TYPE OF SEPTIC WORK: HEW INSTALLATION❑ REPAHRAADDITION DESTRUCTION I3 WITHIN 200 FEET OF BUI 00 IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WNG.I PE RC TEST41 1 10 Y AppNa�tlon I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALS OTHER❑ NUMBER OF UVINO UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEATH OF 9 FEET��PITISUMP SOIL CHARAWCTE ? WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP ❑TYPEIMFO CAPACITY. NO.COMPARTMENTS PKQ TREATMENT RANT❑'DISTANCE TO NEAREST. WELLFOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR IENCLOGED SYSTEM! LEACHINQ UNE ❑ NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER OED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED D W10TH LENGTH DEPTH DISTANCE TO NEARESTt WELLFOUNDATION PROPERTY UNE SEEPAQB PITS LLLLLL��❑jyyyyy�''''D''''''EEPTH SIZE NUMBER DISTANCE TO NEARESTt WELL� N f FOUNDATION PROPERTY LINE SUMPS DTH LENGTH , DEPTH=DISTANCE TO NEARESTt WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEARESTt WELL FOUNDATION PROPERTY LINE } I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DOME IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JO NCOUNTY.HOMEOWNER ORLICENSED AOENT'BSIGNATURE CERT'IFIESTHE FOLLOWING:'ICERTIFYTHATINTHE PERFORMANCE OFTHEWORKFORWHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HNWM OR S ATURE C IMES THE FOLLOWING:h CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO RKM O 8 ION LA OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPLETE DRAWING BELOW. I�PNED X 'f UL &A-v V713D •1V` . TITLE: �� DATE: �I PLOT PLAN(DRAW TO 6CALM SCALE 'to ! 1. NAMES OF a OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. SED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPO BED STRUCTURES, UNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS MINIM wwwoww - --� ...... ..... .... ..... 5ti ...... .... .... .......... ....:...... ....... .... . ,.. .. .. Vic}► a. .... ... . ..............:. .. � . ..._,.-.- ....... .. .. .. .. t vis -�2�P......... f� .............. ............. ...... .. .. .. :.. o'er .... .... .. .. oar I `r�'3ir'tl'^ a .... - - - `.Sfiii wi4t,ILlll4 Gi.U�l I Y ... - � , - I uc I��aFM s�R+r _ LL N�4L.T.. [?1Vi5 QNI �..... `{ EPARTTMENT USE ONLY APPLICATION ACCEPTED BY !f DATE: � AMA: r TANK,PTT OR SUMP INSPECTION 13Y }I lL DATE t I FINAL INSPECTION BY / y DATE �F A/� ADDITIONAL COMMENTS: &[ -ir Wer FZf i }�! • 1 f o Gnliyh . &i k S,JC c !O ,jG 4 hC k-T fes/^ H/(I/ i ACCOUNTING ONLY: AID/ FACS PE CODE FEE INFO AMOUNT TED OIim /CASH RECOVERBY DATE SR A po"T NUMBER INVOICE I ^ .�+ IO•' i Pub.Health Sere.-Enviro.174(3196)