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A p -*N FOR LIQUID WASTE PERMIT. 1R. i , S?Cd- OWN COUNTY PURkIC HEALTH SERVICES Ey'. :' ENVIRONMENTAL HE4'TH DIVISION YYEBER A bAUE, STOCKTON, CA 95201388 y'j,;� ;�� (2091 468 3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUER F-I� (Complete In Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN ,JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Itf'fADDRESSlOR APNI / S /� $ CITY �tx Z «LOT SIZFI-91 -.. OWNER'S NAME ��!(� �, ADDRESS f�i4fR+t-s�� { PHONE_7/47' 36 8'3 CONTRACTOR C AOORESSt<ty C, 1fa�l1 5 � "� S�'L ��r PHONE -S-3V SUS CONTRACTOR ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATTDN ❑ REPAIRIADDITION DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEINER IS AVAILABLE WITHIN 290 FEEL'OF SUI 0.1 PERO TEST(21 1 I HOW MANY APdloatlon s INSTALLATION WRL SERVE: RESIDENCVW COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS:�� NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET PITISUMP SOIL CHARACTEFy G�t.�,E►9;n- WATER TABLE DEPTH CEPTIC TANKIOREASE TRAP ❑TYPEIMFG CAPACITY NO.COMPARTMENTS F PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) 1��,,,+++�� moi: I LEACHING UNE ANO.i LENGTH OF LINES "''+eff � DISTANCE TO NEAREST:WELL FOUNDATION_� f- PROPERTY LINE FILTER RED 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FMOUNDED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOVNDATION PROPERTY LINE SMPAGIE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATIONPROPERTYPROPERTY LINE SUMPS �WIDTHJ _LENGTH_DEPTFIl Z/ LA DISTANCE TO NEAREST:WELLZ�FOUNDATION 36�'�" PROPERTY LINE_ CEJ /!` 019POSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE U i FI HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TH T THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES 1► AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOMEOWNER OR ENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM SUED,I S LL NOT EMPLOY ANY PERSON IN SUC A INNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-C RACTIN ATU CE HE FOLLOWING: 'ICE I HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WO MAN'S COMP CATION 0 A ORNIA.• .2L HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW, *7—Z y Qom! I SIG ED X TILE: DATE: f —Z n ! I It PLOT FLAN(DRAW TO SCALE)SCALE 'to J 1. )JAMES OF STREETSMR RO AREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED �L 2. OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON C I INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, THE PROPERTY OR ADJOINING PROPERTY, r # -- - _ - ., . _ ... ...,.-. . 1' ..... 1 4 r - -. ............ ............ .... - -., Lj J .. ....... ..., .. ...... ...... Y ............. .............. .... ....... ...... .... ........ :. .. ........ . . ........... ... ...... . : ' y 1 ... .... . a�ry` iFL�i! l C/_ ��1' s