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y APPLICATION FOR LIQUID WASTE PERMIT ( `SAWJOAOUIN COUNTY PUBLIC HEALTH SERA I ENVIRONMENTAL HEALTH DIVISION P.O. BOX US, Sa74 EAST WEBER AVENUE, STOOKTON, OA 9S2Q1-368 4 1209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM UAE ISSUED FILE ICemplNt•in TrIpIkEtNI i -' "APfiICAT10N CDRY�-�- IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. 71419 APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC REALT14 SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADpRESBlOR AF"Nr [. L=�. -.�': J j.:� •.: :�., <� A-) CRY L.-/f[ /-�� Lor e17xE e't' I OWNER'SNAME-��Li�-- ..ke. ADDRESS PHONE ✓r`4 �' C" CONTRACTOR - ADDREB 61-; G-.Z J 2C� !/ti /�7�'rr�..I) li'LiCI�� , PHONE SUB CONTRACTOR /1. A011RE88 l''7 ;G. / 1 UC/ PHONE TYPE OF SEPTIC WORK: ( NEW INSTALLATION Q- REPAIIVADDITION © DESTRUCTION 0 IND SEPTIC SYSTEM PERMrTTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF SUILOING.1l ",ERC TEfTIT)1 1 HOW MANY ..i i PP9ootFan INSTALLATION WILL SERVE: RESMENCE13 COMMERCIAL❑ OTHER❑ NUMBTR OF LIVING UMTS: NUMBER OF samoOMS: NUMBER Of I9MPLOYU'E1: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: r PIT/BUMP SOIL CHARACTER; WATER TABLE bEp'rH SEPTIC TANKIORIeAEE TRAP ❑TYPEfMFG CAPACITY NO.COMPARTMENTS P'KO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL + FOUNDATION -j PROPERTY LINE UFT STATION 0 SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYDTEMI LEACHING LINE 13 NO.h LENOTH OF LINES \. ! DISTANCE TO NEAREST;WELL i FILLER SED ❑WIDTH FOUNDATION PROPERTY UNE LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE � MOUNDED 11 WIDTH LENGTH DEPTH_,' DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE#ITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL F-0UNDATk)N PROPERTY LIN1 NUR�IM WIDTH LENGTH DEPTH dISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE L I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RUI ES AND REGULATIONS OF THE DAN 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,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA,' CONTRACTOR'S HIRING OR ' SUR-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS 1B9UED,I SHALL EMPLOY PERSONS SUBJECT To RS WORKMAN'9 COMPENSATION LAWS OF CALIFORNIA.' THE APPUC ART MUST CALL 24 HOUIN ADVANCE FOR ALL REGLLM INSPECTIONS, COMPLETE DRAWING BELOW, SIGNED X - ' ..:; ..-,_�-"1:.• '_-'C r 4 TITLE: `-- -S .'"� %i'' �."I, d G , DATE: / 1!• -./!'` PLOT PIAN{DRAW 70 SCALE)SCALE •,o 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PMOPO9E0 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND"101`09111 STRUCTURES, B. LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED TII?Y FT.ON INCLU rnueasn•Oetq aI Tru EA,TIOR DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPIP'�Y.— .._ l �� 'OA ) N�� f� s .. � ��il i .spa O IN o W f rrr oar L tJ n (x L1„ m b1�1 s t 11S .-.V a AId f i)xl. i4I.CL S'� ! 19 6 f'I)80C I fEELL I ryF.F,Y'I .' k:.�l'IFi ? C:E� i C. NMENTAL HEAL TH 0fosi FOR DEPARTMFMT UNE ONLY ! AP"IICATIUN ACCEPTEp BY DATE: EA: TANK,FIT OR SUMP INSPECTION BY DALE_ ( _ 1 FINAL INeF'ECTION BY ADDITIONAL COMMENTS: / r � 1 / ? iC. Pr1 1 f��ar�rl ,�q 'Itt� 17 '✓I (1 /, r..� BIW' { /�r 1. ACCOUNTING ONLY: AIDN t FAC/ PE CODE FEE INFO AMOUNT REMITTED CHECK ASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE I �C8 �!1 �i - G r7.=3 �I I.