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APPLICATION FOR LIQUID WASTE PERMIT _ M1� ,,:....1N JOAQUIN COUNTY PUBLIC HEALTH- ENVIRONMENTAL HEALTH DIVISIONRVICES y 304 EAST WEBER AVENUE, STOCKTON, CA 9520 r• (209)468-3420 [b� A W Z.a9-•19o-i NON-REFUNDABLE PirDmir EXPI#IES 1 YEAR FPGA)DATE ISSUfp (Complete In Tripliest"i APPLICATION IB HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT 10 CONSTRUCT AND/OR INSTALL THE WORK DESCRfBEO. THIS A CgTION!S MADE MPL1AhCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TfTLE,CHAPTER 9.11 10,3 AND THE STANDARDS OF BAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,E ENTAL HEALTH DIVISION. t -8 AbDRESS/OR APNF -< <1 — k` 'tj �ILrI` 1�j crry ��:/� OWNER'S NAME �L,I' LOT 917E �s!ICI1T- ADDRESS ,1 IaNE DOIPTfb4CT6" 'LJL ADDRESS ^Y_i�jL?i .•' c,� , - ~1' LIC/ 1 N 4CfI SIRS CONTRACTOR ADDRESS tic# TYPE OF SEPTIC WORK: NEIN INSTALLATION � REPAJPJADOITRON bESTAUC TION O IND SEPTIC SYSTEM PERMITTEE IF PUBLIC SEWER t8 AVAILABLE WITHIN 200 FEET OF BUILDING.) PMC TUTWA NOW MANY I INSTALLATION WILL SI31VE: FRESfbENCE❑ COMMERCIAL ❑ APP9wSlm 0 OTHER❑ NUMBER OF UV1NG UNITS: NUMBER OF yMnOOMS: NUMBER OF EMPLOYEE": CHARACTER OF SOIL TO A DEPTH OF 3 FEET; PIT/BUMP SO f IL CHARACTER: WATER TABLE DEPTH SEIMC TANKMREAI:E TRAP ©TYMUF6 CAPACITY NO.COMPARTMENTS PITO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE r UFT STATION❑ 817E TYPE OF PUMP SAND OIL SEPARATOR IENCLOSEU SYSTEM) LEACHING LINE I� NO,0 LENOTII OF LINER DISTANCE TO NEAREST:WELL FOVNDATWN FILTER BED ❑WIDTH PROPERTY LINE LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION- PROPERTY LIRE WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNOATfON SEPAOE FITS C�DEPTH SIZE PROPERTY UNE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS U WIDT14LENOTfI DEFTII DISTANCE TO NEAREST:WELL FOUNDATION DISPOSAL PONDS ❑WIDTFI PROPERTY LINE LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE R HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOTK WILL 13E DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND PERMIT AGNS OF THE SAN JOA COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIED THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WO1K E-0R WHICH THIS PERMIT IS lseUEO,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO MnKMAN'S COMPENSATION LAWS OF CAUFOANIA.' CONTRACTOR'S HIRING OR SUR-CONTRACTING SKTNATURE CERTIFIES THE FOLLOWING:Y CERTIFY THAT IN THE PERFORMANCE OF TIIE WORK FOR WHICH THIS PERMfT 19 ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGLIMED INSPECTIONS. COMPLETE DRAWING BELOW, SIGNED X J�l.�!I Y'� TITLE: C •Lr 1 DATE: 2-1L--J9 ^L C� PLOT PLAN(DRAW TO SCALE)SCALE_ • 1. NAMES OF STnEETB OR(TOADS NEAREST TO OR BOUNDING THE PROPERTY- 2. OUTLINE OF THE PROPERTY,WITH DfMENSIONB AND NORTH OIRIECTION. 4. LOCATION OF HOUSE SEWAGE D18P09AL SYSTEM OR PROPOSED 3. OIMENBIONEO OUTLINES AND LOCATfON OF ALL EXISTING AND PROPOSED STRUCTURES, E LOCATION F SEWAGE THIN R I SYSTEMS, INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. 9• LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY TT.off THE PROPERTY OR ADJOINING PROPERTY. "J .. .. r, .. �- - .. 9999 �E� 1 bAr If3/al31,,1,I D ,,rt., FN ._++... _gid.:.,.- .... ... - :.._,,,. .- ` FOR DEPARTMENT USE ONLY / y7r Afl-LICATION ACCEPTED BY /,/ - �.� - - DATE: / � AREA: �QQ.. T AIIK,TTT On DUMP IMSp ECTfON nY DATE ! / FINAL INSPECTION BY DATE z-/r J f ADDITIONAL COMMENTS:,�11 '!' L� rdL P4<7 Yy A ACCOUNTDNO ONLY: AID# _ FACrF PE CODE EE INFO AMOUNT Itt"t TED pf1EC /CASH RECEIVED BY DATE Sq/PERMIT NIltY1BER INVOICE 74 1 r i Pub,HBBNh Serv.•EnAro.174(3MO) s