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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4883420 NOWNEFUNOADLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEO (Complete in Triplicate) .TION IB HEREBY MADE TO THE BM JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIO APPLICATION 18 MADE IN COMPLIANCE WITH SAN .OUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-111 3 AND THE STAND RUS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEATH DIVISION. JOBADDRESS/ORAPN# IDIF7- 01�, 1{' )j / I I� /TICm`._,,^��, � 1f�w n, LOT SIZE_ OWNER'S NAME C (� 1' TL��/W�. `",�}"�]� ADDRESS L4 L2 19r �'/y11�KT� wn�OTt' pHONE33� -37 1• CONTRACTOR 5(7Tljy�Ll gyaELy ADDRESS F•� UCS. �✓ I Z RHONE SUBCONTRACTOR -ADDRESS UC# PHONE TYPE OF SEPTIC WORK: MEW INSTALLATION Lg REPARIADDITION ❑ DESTRUCTION ❑ WO SEPTIC SYSTEM PERMITTED IF PUBLIC BEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) )BIC TEST1e1 I 1 HOW MANY Appllatlen INSTAl1ATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ IN NUMBER OF LIVING UNITS:� BER OSS OF CHARACTER F SOIL TO A DEPTH OF 3LFEET- OF aBMOOMI: �/SUMP BOUIL CHARACTER:RY� WATER TBU DEPTH D�• ��I1••�� / , IA0-54 SEPTIC TANKIOIIEJU E TRAP ❑TYPENIFG CAPACITY M.COMPARTMENTS�•--{«( • PKG TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE p LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) (p5 LEACHING UNE ❑ NO.a LENGTH OF UNEB DISTANCE TO NEAREST:WELL FOUNDATION P Dvc TY LINE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE LINE (Wr� MOUNDED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION `A.'4'-fFIB - JUR SEEPAGE RTS ❑DEPTN SOE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION�'1 PEIR✓UNF Il. SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION�Y.MNEr DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION IIky1E"� I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BM JOAQUIN COUNTY�Y� -S 71 MATE'[AWB,AND RULER AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR UCENSEO AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFYTHAT'INiNl�tEGA/T��OR]116'VYOw'POR VMMH THIS PERMIT 18 ISSUED.I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATbIj{%�YV6�1'R 1i✓ 1MILA♦jlt�` OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18[OWED,1 BULL EMMOY NtI IBUBJECT TO WORKMAN'S COMPENS LAWS OF CALIFORNIA.- THE DA APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR,A{LLL RREGMRED INSPECTIONS. COMPETE DRAWING BELOW. I G SIGNED X A ��I J-[/� TRUE: H /C�✓(,(/L�'v/DATE: PLOT PIAN(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 POPO6ED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTUNEB AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R.ON INCLUDING COVERED AREA$SUCH A8 PATIOS,DRVEWAY6.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. CJ I r �I r _ -y c _ PROPOSED 30ILDIAlu ,IB7,1 / t - II ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: AREA: 4 TANK,PT OR SUMP INSPECTION BY DATE I I .FINAL NBPECTION BY DATE �D Lt L /�/-1 ADDITIONAL COMMENTS: OIL_ SEpFR�'CU2- - '-� US� n)/ ( N Ec_�iD�� - ACCOUNTING ONLY: AID( FAC# PE CODE FEE INFO AMOUNT REMITTED CHEC ASH RECEIVED BY DATE M I PERMIT NUMBER INVOICE I P�// ae 140 -,?y II-�I - S 6 OA3LI71