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Gr j:�'_-`;G`, APPLICATION FOR LIQUID WASTE PERMIT -„ N'JOAaUIN COUNTY PUBLIC HEALTH SERVICE;, ENVIRONMENTAL HEALTH DIVISION 34 P,O, BOX 388, 4 EAST WEBER AVENUE, STOCKTON, CA 95 I-M (209) 468.3420 NON-REFUNDABLE PERNIT EXPIRES 1 YEAR FROM DATE ISSUED Momplab in Triplkato) 1 APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN —JOAUUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 O.&AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. c; -JOS AODRESS/OR APNN ( CITY _ LOT812Eal. !� OWNER'S NAME_ �0!1'� Qi.T'}lyp �' I _ADDRESS +�tGd S� PHONE -► I CONTRACTOR ADDRESS [�- LIC:r PHONE f ,/�/� SUB CONTRACTOR r r VVI- ADDRESS ] �� ..,��,s� UCwiCOinR .i y PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIAOOITION ❑ DESTRUCTION 0 NO SEPTIC SYSTEM PERMITTED IF PUBLIC$EWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.1 PM TESTIA L 1 NOW MANY � ; APp9oetlon a . ”-INSTALLATION WILL SERVE: FRESIDENCE COMMERCIAL ❑ OTHER❑ NUMBER OF UVINO UNITS: 1 NUMBER OF BEDROOMS: """.. NUMBED OF EMPLOYEES: may+ CHARACTER OF SOIL TO A DEPTH Of 3 FE PITJSUMP SOIL CHARACTER: WATER TABID;DEPTH. �—SEPTIC TANKlGREASR?TRAP �FOL +s'I1. CAPACITY � _ NO.COMPARTMENTS _•�.. _ _ PKO TREATMENT PLANT❑ DISTANCE TO NEAREST. WELL �_ -r FOUNDATION L PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSEO SYSTEMI _ F LEACHING UNE ,�NO.a.LENGTH OF LINES �y'�^ DISTANCE TO NEAREST:WELLt�'� FpUHDATION ��' PROPERTY UNE ' FILTER BED ❑WIDTH LENGTH DEPTH 019TANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ,_,MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL- -��FOUNDATION PROPERTY LINE SEEPAGE PITS �bEPTH SIZE �'x G` NUMBER �7 DISTANCE TO NEAREST:WELL_-.,c �FpUNOATION O1 PROPERTY SUMPS 13"bTN� LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOCAL PONDS Cl WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE n" I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES SAND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT MITHE PERFORMANCE OF THE WO W FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OFR SUB-CONTRACTINQ SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS. COMPLETE DRAWWNO BELOW. y }SIGNED X TITLE: ri - Q r DATE: lqr2 PLOT PLAN[DRAW TO SCALE)SCALE 'to - 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <. 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 LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY- .. ..i. -:.. -,...... i.�V :,.., - .. ...: i ., .. ..... ., - . .... .. .. oaf .. ... ... a .. .\ .. . :... ..... .... .. >.. 4 .. .... VI _. . € ' .....'. .. _ . ; ... ..0 . .. T . 1996 - . ... ....... . . .. .....