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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESENVIRONMENTAL HLTH DIVISION SEPTIC 304 EAST WEBER AVENUE,,SSTOCKTON,CA 95202 5Ce (209)468-3420 NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICBmy1/tE M TRIpHut.l APPLICATION IH HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND.DR INSTALL THE WORK DESCRIBED. THIS APLICATION Ie MADE IN COMPIJAHCE WITH BAN JOAGUW COUNTY DEVELOPMENT TITLE,CH ER 9-1110.3 ANO THE STANDARpB OF BAN JDATUIN COUNTY"LIC HEALTH SERVICES.ENVIRO/N\MIE�W AL HEALTH DIVISION. JOB ADORE SS/OR A`PNNV Z 1 .AAS //� ( �/-�/ CETY-�1\_��L t J,y LOT 81I �n/�'//�L OWNER'S NAMF� L I In' 1' • l.V� .I �� Y R7oNE��E��P��j'[.��l�Ly�-T CONTRAC..D-•A-PAP,Q15H - SQN '1 NCADDRESS I LJL 1-J W-W 1 Lam)-W6y,.. PHDNE P 6 jg5 T BUB CONTRACTOR ADDRESS LIO/ PHONE TYPE OF SEPTIC WGRK: NEW INSTALLATION❑ REP/URIADDITION DEATRUC TION❑ T NO SEPTIC SYSTEM PERMITTED IF PLIBLK SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING) PFRC TESTHI 1 1 HOW MANY MPSaSPn INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL OTHER❑ NUMBER OF LMNO UNTS:_.-J�NUMBER OF SEDROOMS'' : NLIMSER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPMN OF 7 FEET:CC 1T Pff/BUMP SOIL CHARACTER: WATER TABLE OM SEPTC TANK/ORE"I TRAP ❑TYPEIMFO CAPACITY NO.COMPARTMENTS PKO TIIEATMENT PUNT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ASSIZE TYPE Of P SAND OB SEPARATOR(ENCLOSED SYSTEM) /'� rT(^J LEACHING UNE RAI NO.S LENGTH OF ONES _DISTANCE TO NE AREfIT:WELL , FWHDAIN)N W P1giSRTY UNE 1 ''v FILTER STD ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTYUNE J SEEIAOE PITS X OEPTH25_SIZE _NUMBER_DISTANCE TO NEARFST:VWU IM'FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTN D(STANCE TO NEAREST:WELLFOUNDATION PRDPERTY UNE DISPOSAL PONDS ❑WIDTN LENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTEY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK Will BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AMD RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT W THE PERFORMANCE Of THE VVOIK FOR WITCH TLKB PERMIT is ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR B SUCONTRACTING SIGNATURE CERTIFIES THE FOLLOWIFIO:9 CERTIFY THAT IN THE MWOFMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WOFKMCOMPEMBAT IONL{/L��JWPBI LOFF1I CALIFORNIA.- THE APPLICANT MUST CALL 2/RROURS IN ADVANCE FOR ALL TO�URED/AINSP PECTIONS. COMPLETE DRAWING BELOW. BIONEOX i t /\l/I/1 VJ - TRLEt &IJm 1Y�� DATE PLOT PAN ff!RAW TO SCALE)SCALE__'TO I.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING Th*PMPERTY. I. LOCATION OF HOUSE SEWAGE DISPO ALL SYSTEM OR PRDPOSFO 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 0. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING Co%q FD ARE"SUCH AS PATIOS.DRIVEWAYS,AND WALXS. THE/PROPERTY OR ADJOINING P OPERTY. V� _ r u, 1 1 . . 1 auW ) 1 .. _ - r { I r 1 ll1' �. ? 1 of ricE .. ..J. _. ._ a _ I r l r P YM � 4- E}>`SZ'..99 FRDkIi'A6�(L£rA^C3 _ ....�... ,.. _.I I - ;.. ..; SANJGwuUlh .I _PUBUCMEALTri . ' _. - .....,. ENVIRONMENTAL M - - �/ DATE: �_- AREA: APPLICATION ACCEPTED By ION DATE TANK.RT OR RI,MP WSPECTION TIY DATE / / FIN T ADDITIONALCOMMENTS.-_ ACCOUNnNO ONLY: AID. FAC/ PE CODE FEE INFO AMOUNT REAR I TED N ASH RET-FIVED BY DATE i11 I P9WKT NLIFam INVOICE/ -2- U .QQ L,_