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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CImPIetl IR TrIPFle6h1 APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOO A PERMIT TO CONSTRUCT ANDMIN INSTALL THE WORK DESCRIBED. THIS APPLICATION 19 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE BTANOARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDUSSIOR A1PN/FI IS00 e MAD,�4"4 JeO DUTY ✓A//'/�P LOT SIZE A OWNER'SNAME •_ P ADDRESS 0•50)c998 peLV15o GA PION xd / CONTRACTOR Al-WY AZI ,ESi�AReN ADDRESS 6. 6oX3749 7URL 6k LIC, PHONE 611*,403 SUBCONTRACTOR ADDRESS LIC, PHONE TYPE OF 6EPTIC WORK: NEW INSTALLATION ❑ REPAIMADDIT1ON ❑ DESTRUCTION Cl IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDINGJ PEW TEIM1.1 I 1 HOW MANY APNPAtlon I�/P INSTALLANON WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF WINO UMTS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEFT: PLTIBUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANIUOREASE TRAP ❑TYPE M CAPACITY NO.COMPARTMENTS MO TREATMENT PLANT❑ OLITANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR IENCLOSED SYSTEM LEACNNO LINE ❑ NO.S LENOTE OF UNEN DISTANCE TO NFAMAT1 WELL FOUNDATION P MRTY UNE FILTER IED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE IEEPAOE HIS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BUMPS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑MDTN LENOTN DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCOPDANCE WITH SAN JOAWIN COUNTY OBDINANCE8 AND STATE LAWS.AND RULES AND REGULATIONS OF THE SAN"AWIN COUNTY.HOME OWSIER OR UCENBEO AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOIWIA.' CONTRACTOR'S HIRING OR 9UB-CONTRACTING mqtopum CEBrIFIF R FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE M!U`K FOR WHICH THI9 PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP A ON LAWS O ALI PENIA.- THE APPLICANT MUST CALL 24 HOUSES IN ADVANCE FOR/ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED% TITLE' (JNLeV Y/ DATE: V"011-7 ROTN OMW TO 6CALE1 SCALE 2 1 � -jr 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDIN THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROKIRTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE NSFOSAL SYSTEMS. 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED MEAS SUCH AS PATIOS,DRIVEWAYS,AND WMAS, THE PROPERTY OR ADJOININD PROPERTY. N ................ w y w y 12-0 C FFQAMP MAVka6 a N PAY M Efv ! RECEIVED SEP 14199 2 GAN-JOAQUIN:k; UN PUBLIC HEALTH SERVICES T6 ENVIRONMENTAL HEALTH DIVISION 1� FOR OEPMTMFNT USE ONLY ART'LICATION ACCEPTED BY 'K� � �'O.T�P_''F �.� DATE:IY4 APEAI'TANK,F T OR BUMP INSKCTIO14 BY DATE / / FINAL INSPECDATE / /J Il ADDITIONAL COMMENTS: Jt pX-ET'I- 1 d Z ACCOUNRNO OMLT: AUDI FACT HE CODE FFE INFO AMOUNT RFIAI ITED CNECIU ASH RECEIVED BY DATE SAI PERMIT NUMBER INVOICE I Pub.Health SEN.-Enviro.174(3/96)