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APPLICATION FOR LIQUID WASTE PERMIT or p'1" SATraOAQUIN COUNTY PUBLIC HEALTH L-Y ICES C[- 1 ENVIRONMENTAL HEALTH DIVISION < - 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468.3420 / NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compute In Trtloliutel / AP (CATION 18 HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT MOON INSTALL THE WORK DESCRIBED. THIS APPUOATION I8 MADE IN COMPLIANCE WITH BAN JOAQ UIN COUNTY DEVELOPMENT T/R/1LLE/L.ytf HAP`EER 9-1110.3 AND �/B(^T1AANDANII'D�OFF7SAN JOAQUIN CC/O IVTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH OINBpN. ty, A JOB ADIMESSIORR CAS/MI" ✓ - 1 1/ 1 Li I•'`( 1 4 y' L�y "� t crry ^)�� 1�� q%9-1i SIZE 1f��)" OWNER'S NAME I'XIY E eCLE1_ fk 1J ADDRESS ,214 7, !� C— Fn� UlqTI 2a PIONEq O /'1i ) , CONTMCTOn S1rL f` ADDRESS me PHONE SUBCONTRACTOR ADDRESS LIC# PION( TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ PREPA UADNTION ❑ DESTRUCTION ❑ ONO SEPTIC SYSTEM PERMITTED IF PUBLIC SEYhR IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PAC TEITPI I 1 HOW MANY - 'Yom.I/ AppEostlan INSTALLATION WILL IOLVF. RESIDENCy�y COMMERCIAL ❑ OTHER 11NUMBER Of"NO UNUM / NUMBER`OF BEDROOMS: NUMBER OF EMPLOYEE(: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PTISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANIVOUEASE TMP ❑TYPEIMFG CAPACITY NO.COMPARTMENTS MO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMPSAND 014 SEPARATOR(ENCLOSED SYSTEMIIL TMI1 LEACHING ONE Al NO.a LENGTH OF ONES j DISTANCETONEEST:WELL! L� / FOUNDAN �O MOPRTYUNE �OO 4O J��FJ NI MOOR BED ❑WIDTH MNOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION P10PRTY LINE MOUNDED y❑�WIDTH ^ LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION c PROPERTY UNE SEE➢AGE PT& M1]I DEPT" LS SIZE-3� y NUMBER ) DISTANCE TO NEAREST:%VEI-L MUNDATTONO I RgFERTV UNE,3 CC) ) SURAPS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION MOPRIY UNE gSPOSAL PONDS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL MUNDATION PROPERTY LINE — I HEREBY CERTIFY THAT 1 HAVE MEPARM THIS APPCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WREN BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOVIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PIFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION UUWS OF CALIFORNIA.' CONTRACTOR'S HI SNO OR SUB-CONTRACTINO BMNATURE CERTIFIES THE FOLLOWING''I CERTIFY THAT IN TI HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS. COMPLETE DRNMNG BELOW. SIGNED EQ✓If��G,� TITLEOry N fy1 c-n- DATE: ��G - / P� PLOT PAN(DRAW TO SCALE)SCALE -He 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RAD US OF ONE HUNDRED FIFTY FT.ON .. INCLUDING COVERED MEAS SUCH A8 PATIOS,DRVEYVAYB,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. W n\ 0 oh DID CIO K5 — Y kJAYMEN (21 y = L FEB 2 6 1999 CLIA li! AIY�i TI APTLICATION ACCU?ED BY FOR n o�MTMQUSE ONLY GATE: �` — AREA'' TAN< R SUMP INSPECTION 1N1 BY -- 1 �OATE IZ / NAL INSPECTION 0 �T., DATER[, Z 1 U ADDITIONAL COMMENTS: 2JA VeGe" �/�Q ✓54-" U 1F elfTO) ACW/ .L'-4/LA dD ) ✓6alA• tTA�`I'IG OOAU L 1 ACCOUNTING ONLY: AID# FACT P CODE fEE INFO AMOUNT REMITTED EC ABH RECMM ED BY DATE SR/PERMIT NUMBER RNVOICE I Pub.Health Sew,-Enviro.17744y(3,/96)/ 1/l7�t 1 In /'i .� 101 R