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'-APPLICATION FOR LIDUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOADUIN ST., STOCKTON, CA 962010388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TFp1'Xub) APPLICATION IS HERESY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESC WEED. THIS APPLICATION I6 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE. `CHAPPTTE�RE 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PLWJC HEAL/T/1�yJi�f9\\VICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESIHOR ApRTY �L S SJ / /O `P7' I•L CA • CffY�F7 ! Iy0 N -6-vv- SIZE_( .J OWNER'S NAME �JAV I'At°19NA' /"10h Ler ADDRESS '�MVM.B __PHONE �`(4- S'Orf CONTRACFOfl�(Y//1G •FI 50 ACORESS �Z JF40 eO U/Y 14ye'l STO uc# yy�L�'/ PHONE SUB CONTRACTOR ADDRESSUC# RHONE TYPE OF eEPTiC WORK: NEW INSTALLATION 13REPAMUAGNT10N A••qq DESTRUCTION ❑ ;NO SEPTIC SYSTEM PERMITTED IF MBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TE/T1.1 I I(IOW MANY IIpp APPewEon# LL INSTAATION MILLSEILVE: RESIDENCE Py COMMERCIALCI OTHER 0 NIIMBEII OF"NO UMTS:(NWBEII OF BEDROOMS: NUFam OF EMROYEEB: N CHARACTER OF SOIL TO A DEPFH OF 3 FEET: sf1A(d RT/SUMP SOIL CHARACTER: WATER TA DEPTH I w SEPTIC TANKmRFAEE TRAP ❑TYPE/MFG CAPACITY NO.CORAPARTMENT9 RIO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELLFOUNDATION TROPERTY LINECIA CIN LIFT STATION❑ &ZE TYPE OF F/U,MM�P SAND OIL SEPARATOR(ENCLOSED SYSTEM)``^^ LEACHING LIME Ippr W.6 LENGTH OF LINES XJ � DISTANCETONEAREST:WELL�FOUNDATION .yynnPROPERTV UNE S# FILTER BFO ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED 13 WIDTH LLNGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PRORifTY UNE O SEEPAGE PTB 0 DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE /r SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DI6POBA PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,ANO RULES AND REGULATIONS OFTHE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CEHTIFIESTHE F LUOWING:'I CERTIFYTHAT IN THE PERFORMANCE OFTHEWORK MRWHICH THIS PERMIT IS ISSUED,I SHALL HOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO MWMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR - SUSCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOWtMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION& COMREWINW. FE DRAG BELOW SIGNED X fJ TITLE: DATE: ROT RAN(DRAW TO SCALE(SCALE -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE FROPERTY. 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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. J4J lR./� Shed / mi,k 14 fi7 `g� jo )--IO V .gN- Iva 4 CH C/T LJ(H/P SoL./ L/:YP 1r I IIt Ik I'- iN ly W 1 1 - I _ if eb L_Pr Rd- FOR DEPARTMENT USE ONLY DATE. APPLICATION ACCEPFEO BY \/ �, � TA ,PTT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION By /V1A/Tti(L ✓O DATE L ZI � I NKys ADDITIONAL COMMENTS:�jTY 1 •V L�/1I` ACCOUNTING ONLY: AIDE FAC# PE CODE FEE INFO AMOUNT REMITTED CHECX#ICA6H RECEIVED BY DATEW/PERMIT NUMBER INVOICE a 4211 II _S I $�•� 0��3