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APPLICATION FOR LIQUID WASTE PERMIT 5AN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX S88, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (2081 4883420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compliti In Triplliiti) APPUCATION 18 14FREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOR(DESCRIBED. THIS APPLICATION 18 MADE IN COMMIANCE WITH SAN JOAQUIN COUNTY D ILO ENT TITLE,CHAPTER 9-1110.E AND THE STAN ARDS OF SAN.10 OUIN f UNTY RIBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. //�rF/�J679-06 A-Pnu /,-,1-v�d�- lir /S- 7/ - JOB ADDRESWOR APN# .XJW I'TI-u�Sr fM I.Ip�✓l.. /y�/}-Iy' />-F q-- /LLQ �L.QS CfiV _YJYTIJyLEf1� —J=----�—_ LOT SI2E OWNER'S NAME �S r�[�S AUDRE66 SfIYYI'� PHONE CONTRACTOR B &t �� --AUDRE66 LIC# RIONE SUBCONTRACTOR S!'/— �L_ _ _AUDRES6 Zb ZE_ 25, /'1'L�/L'r[•� S ]`•' LIC# SZ-Z66 PHONE 9y�-{3YS t— TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADOTION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TFST01 I 1 HOW MANY APMlentlun# �2 97-003 INSTALLATION WILL SEINE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ GP? - / / NUABER OF LIVING UNITS: NUMBER OF BEDROOM& NUMBER OF EMPLOYEE{: 6;6;P01-7- ^�I CHARACTER OF SOIL TO A DEPTH OF 3 FEET: RTISUMP SOIL CHARACTER: WATER TABLE DEM14 SEPTIC TAN UDSRSASE TRAP ❑TYPEMFG ___CAPACITY- NO.COMPARTMENTS (VAI PKG TREATMENT RANT ❑ DISTANCE TO NEAREST: WELL__ FOUNDATION PROPERTY LINE LI UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.4 LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PHOKITFY LINE SEEPAGE PITS ❑DEPTH 612E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SLSAPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION MOMPFFY UNE DISPOSAL PONDS ❑WIDTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE T- I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WRH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULER ••1 AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER ORLICENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'ICERTIFYTHAT IN THE PERFORMANCE OFTHEWORK FORWHICH S THIS PERMIT IS ISSUED,I SHALL NOT EMROY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR 81.0BLONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO N6ATON LAWS PDALI RNIA.' THE AMl1CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REBURIED INSPECTIONS. COMPETE DRAWING BELOW. SIGNED TITLE: DATE' 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR FWPOSE0 Q 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PHOMBF.O STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY ET.ON INCLUDING COVERED AREAS SUCH AS PATIOS,ORVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. --R--- K � I Y I 2 ee 1 . .maw S-. � � i F' •�� 1 1 �Fj 1 3 Li ® Jk 1 1 WAS tt .T 7r--G7— L-Dc4T� } I V ( 1 AN 101997 SAN,JQAQUIN GOUNTV FOR DEPARTMENT USE ONLY r ENVIRONMENTAL HEALTH DIVISIOP APRIC,ATION ACCEPTED BY C . DATE / 0h-7 AREA: TANK,PIT OR SUMP INSPECTION BY DATE I / FINAL INSPH TION BY DATE G I I 17 I ADDITIONAL COMMENTS: rJ ('Q'/Le�C) re- rczd 2 F'R! K-t�D _ -F#- 4 q-55� ,Z PEsRL A�CDCPo/-{skL 15p.OD ACCOUNTING ONLY: AID# FAC# PE CODE FEF INFO AMOUNT REMITTED CK /CASH RECOVED DATE SRI/PEWWIT NUMBER INVOICE# - -z 52J 3g O as"8