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lPay, PPLICATION FOR LIQUID WASTE PERMIT SAAJOAQUIN COUNTY PUBLIC HEALTH SERVICES'". ENVIRONMENTAL HEALTH DIVISION P,O, BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (2091 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (Complete in TrglkBtB) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMA INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMEJNTT TITLE, CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMMENTAGL� HEALTH DIVISION. JOBADDRESSIORAMI 241 .Y.S � f� "73 �+%iJr� `-C_� _ CITY L%Y✓C.�L'V I�� LOT SIZE WA OWNER'S CONTMCTOR ADDRESS LIC/ PHONE PEEL TES71.11 1 HOW MANY SUBCONTRACTOR ADDRESS UC/ PHONE NUMBER OF LIVING UNITS: • NUMBER OFF BEDROOMS: NUMBER OF EMMOVEIES O / TYPE OF SEPRC WORK: NEW INSTALLATION Li REPAR/ADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET Of BUILDINO.1 PEEL TES71.11 1 HOW MANY C/. INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER � Q ) (J •[I t"q Tf- -J'T APtllo.eon s NUMBER OF LIVING UNITS: • NUMBER OFF BEDROOMS: NUMBER OF EMMOVEIES O / CHARACTER OF SOIL TOA DEPTH OF 3 FEET: C Z PITISUMP SOIL CHARACTER:'', I-}'^y/lam_ WATER TABLE DEPTH �� • "i%1 SEPTIC TANKIMEASE TRAP ❑ TYPL/MFO �Dl ✓fT./l. L '�` CAPACITY NO. COMPARTMENTS PKG TREATMENT MANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) SIZE TYPE OF PUMP SAND �0 LEACHING LINE NO. B LENGTH OF LINES '/ — q /0/� 7 ' DISTANCE TO NEAREST: WELL O 1 FOUNDATION J`O 1 PROPERTY UNE ':;Z V / � , FILTER BED ❑ WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE SEEPAGE RTS 1' OEPTH,? Ll SIZE NUMBER DISTANCE TO NEAREST: WELL &0 tZ I FOUNDATION S'� / PRDMATY LINE SUMP& C1 MOTH LENGTH DEPTH DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑ WIDTH LENGTH DEPFH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE - I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS, AND PULLS (N AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP LAWS OF!(C�AL/ff/O/�N1) THE AP%I^CANT MUST CALL 34 HOURS IN ADVANCE FOR ALL REQUIRED INSP£CAON&. COMPLETE DRAWING BELOW. m [�] SIGNED % ��/2-{jr / TITLE: i,{ )r l� DATE:A /— / PLOT PLAN (DRAW TO SCALE) SCALE 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 RADIUS OF ONE HUNDRED FIFTY ". ON INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. THE P KITFY OR ADJOINING PROPERTY. 21 P)T D 0 SL' i `L x Lb 0 r - J F— (j n n,q `Jp �,1 K. RF OCT ` 1 1997 aAly JOAC4UIN. CdUNT-Y U80C HEALTH SEgVICEs <NVmONMP,NTAL NNALTf+ C,,(iN FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY A'n � i DATE: TANK, RT OR SUMP INSPECTION B�IY�/ � ('j / '/D1pAT �//I �/ / FINAL INSPECTION ADDITIONAL COMME.TQv. 1 Q MMA' V, A'YI�.A-f_L11✓. !J >!] �_ f"— .Y' / y' ACCOUNTING ONLY: I AID/ FAC# C AREA: -Z— // R.TF i0 1 S 197 PE CODE FEE INFO AMOUNT RFMITTED CHECKS/ SH RECEIVED BY I DATE I M I PERMIT NUMBER INVOICE 9