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APPLI' -ION FOR LIQUID WASTE PERMIT SAN JO COUNTY PUBLIC HEALTH SERVIC._ ENVIRONMENTAL HEALTH DIVISION P.O.BOX 380,448 N.SAN JOAQUIN ST.,STOCKTON,CA 95201-0391 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICamPNb I.TripUrstel is made is hereby made to the San Joaquin County for a permit to construct and/or install the work described. This appticat fa made jn nvicowt ance with Sen Joaquin County 0eve l opment Title, Chapter 9-1110.3 and the Standards of San Joaquin County Pubtic He. Services, Envirorvnentet N<el[h Division. Job Address/or APNR_ 22d , m '/J'n /{ CCity L i�i..- lot Size 3-09c.(.1 Dwner's Name. Wi9-t I11e..-c%IW Address ZZ//D E'./ ir'llvo— /Qo act Phone 897-3, Contractor 6 w,..r.,/•(?4//95�P Address Sg.y a� /f b a " / LIcS Phone_ Sub Contractor Address LicS Phone TYPE OF PEPTIC WORK: NEW INSTALLATION I I REPAHUADDITION I I DESTRUCTION I I PERC TESTW I 1 New sn; /r e% (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) (J o// svTb•%' TT..dy f- Sym 'c fysyj,.-,s. Or:.9) Land Use ApRBambe,J I retaliation will serve: Itaidence_ Cananrcial_ Other_ Number of hying unit"_ Nuibar of bedroosmm_ Number of seg Lo...."__ -- Character of soil to • depth of 3 tat" pit/Sump Soil Character: - Water Table Depth SEPTIC TANIUOREABE TRAP [I Type/Rfg Ce .cit P Y No. Compartments. PRO TREATMENT PLANT [ I Distance to nearest: Weil Fouvlatfon Property Line_ LIFT STATION(T Size_ TYPO of Pump__ Send OIL Separator (enclosed system) LEACHING LINE D No. L length of lines Distance to Nearest: Welt__ Foundation_Property Line FILTER BED ❑ Width_ Length_Depth_ P " • Well. Foundation_Property Line_ _ MOUNDED [7 Width_ Length_Depth " " Well_ Foudation_ Property line_ D SEEPASE PITS [1 Oepth_ size__ Ntnber_ ^ " Wet l_ Foundation.Property Line SUMPS Width_ LmBth__Depth_ " " Well_ Foundation—Pro pertY Lire_ _ DISPOSAL PONOS [I Width_ Length_ Depth_ s ^ Well_ Foundation_ Property Lim— ' "' ine_ I hereby certify that 1 have prepared this application end that the work will M done in accordance with San Joaquin County Ordinenc and State Laws, end Rules and Regulations of the Sen Joaquin County. Nome owner or Licensed agent's signature certifies the fel Lowi al certify that in the performance of the work for which this permit is issued, I shall not to an t0 become subject swer t0 workmeMs cmpenseti on laws of California." Contractor's hiring employ y Person m such a ifies or subtcontract jng signaturesubject certifies n following: al certify that in the performance of the work for which this permit is issued, 1 shall employ persona subject to workman cmpencation laws of California." The epplesst svt nU E4 hove In advance feral nMuinl Inga.ejeae. Complete drawing below. Signed X Title: � , Date: 10-1,4-,9• P PLAN (Grew IMI. Scale " to 1. Names of streets or roads nearest to or boudjng the property. 4. Location of hove ..wage disposal system or 2. outline of the property, 'with dimensions and North direction. proposed expenaf on of sewage disposal system 3. Ofannsioned outlines and location of all existjng and proposed 5. Location of wells within radius of 150 ft. structures, including covered areas such as patios, driveways, the property or adjoining property. end walks. `it` R rT , nt.vi-i SE VIp,-' Oz a '6 A Z' D � O 11 ri ov• z N7 o' £ / % Z R DEPARTMENT USE ONLY Application Accepted by //// !- Date: Q /7,l 4� Area: '17�% Tank, Pit or Sump Inspection by ® Date / / First Inspection by Date Additional Comments: ACCOUNTING ONLY: AIDS FACS PE CODE I FEE INFO AMOUNT REMITTEDECK CASH RECEIVED SY DATE SR 1 PERMIT NUMBER INVOICE f ,t.2z 23 b [Dim bo z