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avo Vz Fj APPLICATION FOR LIQUID WASTE PERMIT n SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 Fi (209)468-3420 NOW-REFURDARE PERMIT EXPIRES I YEAR FROM DATE ISSUED 4 (Complete In Triplieatt) APPLICATION 19 HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANbMA INSTALL THE WORK DESCRIBED. THS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOVIN COUNTY DEVELOPMENT �TITLE. CHAPTER�9-11 10.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. r JOB ADDRESSPOR APR'1 g;L{,S )3` �f� V4 FZ _ -__CRY/ /. 1 F'y LOT SjIIE� OWNER'S NAME ADDRESS gjjTI nY F��%!.� eG u -- P"ON�Z.`aS'� !I VZ CONTRACTOR��' ,_ADDRESS LIC/ PHON r L BUB CONTRACTOR ADDREBB LICK PHONEY TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DEBTRL1CTToN INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUIU NlG.I PWC TESTIU I I HOW MANY AppNmtFen! . F INSTALLATION WILL SERVE: RESIDENCE 11COMMERCIAL 13OTHER ❑ NUMBER OF LING UNITS: NUMBER OF EWA OMB: NUMBER OF EMPLOYEES: F CHARACTER OF SOILTO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASE TRAP ❑TYPEUMFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE W ` LIFT STATION❑ 612E TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) } LEACHING LINE ❑ MO.B LENGTH OF LINER bfBTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE F." FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED [3WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE y BEEPA09 PITS ❑OEFTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE BLIMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE f I I HEREBY ERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUINCOUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CEFMFI ESTHE FOLLOWING:'I CERTIFYT14AT INTHE PERFORMANCE OF THEWORK FORWHICH THIS PERMIT It IBSIIED,1 SHALL NOT EMPLOY ANY PERSON M OUCH A MANNER At TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIRDRNIA." CONTRACTOR'S HIRING OR RUB-CONTRACTING SIGNATURE CEKMrES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO( I: WOFKMAN'B COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INBPECTIONB, COMPLETE DRAWING BELOW. I. I�f . SIGHED)( TITLE: BATE: F PLOT PLAN IDRAW TO SCALE)SCALE 'Gn 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OVTUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.F, _ 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. 0 S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED MEAS SUCH A$PATIOS,DRIVEWAYS,AND WALKS. �J THE PROPERTY OR ADJOINING PROPERTY. ... . . .... ...- ...... .. - .. .. .. - ....................................................... .-._.,..., I ......:........ - .. - .. .. ..,:...., ..:..... ....... .... -.... ..... .. .. .. .......... .................... . ....... ..... ....., b �� 'I ..... ...... APR...�'.4:x.998.:. 7PSAWroticry .. . :,... IJVIF tiFA�Af iqI r ........ : . .............................. . .. ......... ...... ........... .............. ........... . ........ .... ................... .......... .. ..... ....... .......... .. ....... ............ .. . . . .. ... .. .........