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FAPPLICATION FOR LIQUID WASTE PERMIT r SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICExs ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 904 EAST WEBER AVENUE, STOCKMN, CA SMI X88 (209) 460.3420 NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED (Complete W Tripkata) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED, THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3+AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVtPES,ENVIRONMENTAL HEALTH DIVISION. y,}� r J0B ADDRESS1OR APNI _ M f { �1n {° R' 1 OWNER'S NAME Tom/ 1'Y .(�4^UYI ,._,�ADDRf88 c'4t $fi PHONE__ �(}� CottrmCTOR ADDRESS LPC# PHONE L SUBCONTRACTOR y r t'1 'Ci {�[.( �ADDRESB_ ?O _19Sd LIC/ _PHONE - v TYPE OF SEPTIC WORK: NIW INSTALLATION RFFARUADDITION ❑ OUTRUCTIO00❑ No SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF SUILDING.) P91C TEST(a)[ [HOW MANY ' i APPRO+Son• w• INSTALLATION WILL SUM: RESIDENCE P*"COMMERCIAL. ❑ OTHER 13 NUMBIER OF LIVING UMTS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYM: CHARACTER OF SOIL TO A DEPTH OF 3 FE { st{�(�P.n PITMUMP SOIL CHARACTER: WATER TABLE DEPTH G& 1 SEPTIC TANIUOREASE TRAP 1MF0 1,. 5='oh g Le CAPACrTY —L'�, 7)n NO.COMPARTMENTS., PKO TREATMENT MJLNT 11 DISTANCE TO NEAREST: WELL ( FOUNDATION x ^� �. PROPERTY LINE _— �[� 4 LIFT STATION© SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACIaRiO UNE 0-NO.B LENGTH OF LINESa DISTANCE TO NEAlLEBTr WELL FOUNDATION_PROPERTY LINE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTIL DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ySEWAGE PITS Q'DEPTH .1 SIZEG NUMBER_ DISTANCE3� BTANCE TO NEAREST:WELL .-�FOUNDATION (01) PROPERTY LINE_ BUMPS 13 WIDTH'�V LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PAOPERTY LINE DISPOSAL PONDS 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE n F1 HEREBY CERTIFY THAT I HAVE PREPARED TRIS APPLICATION AND THAT THE WORT(WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING''I CERTIFY THAT INTHE PERFORMANCE OF THE WOR(FORWHICH THIS PERMIT 18 ISSUED,1 SHAD.NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR r SU"ONTRACTING SIONATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT)$ISSUED,I SHALL EMPLOY PERSONS SUBJECT To WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,* THE APPLICANT MUST CALL 24 HOURS IN ADVANCE I"ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE- DATE: Arrp ROT PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED y 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, E. LOCATION OF WELL$WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREA$SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. y�• .... ....... .......... . :... ........ ..... ...... .....'.. w : .r ` .. .. d .��..: : . ............ .. :... ..... .. ...?. .. .� .. c. .:.... .. -- -. .. .. .. r L'YL .. .. .. ...... . . . .. .. _ -.. _ '.... .... p01 .;.....:..,�;... .. ...,.., <..... :..............'.....;...... ...