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APPLICATION FOR LIQUID WASTE PERMIT Dais-zo 4AN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4883420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110/3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENV1RONMENTAL HEALTH DIVISION. JOBADDRESSIORAMO / S UD t'j � �o �^} (` �J CRY �rr < ,/ /� LOT 812E OWNER'S NAME ,'/�AJ ) /�D\/�P l FI"�( Y Y✓) ADDRESS / SS/ /iT-) !�� I' Z0.0, PHONE ;�9 SCEPo S d CONTRACTOR_S r t L/A H7 L lj" J✓ l/ /30X of �A�ADDRE56 /1�V � 3 � (ICI S 9 9 34/ PHONE '�9 2 r 7 Z SUB COMPACTOR ADDRESS T "o'A,7--Aj C/} gSL $�b Daz [4I(o <FZS ( 97 UCIP PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) PSAC TESTbI 1 I HOW MANY --//&— / L, APWlwtlen INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER {'I UY / C_ jP51t-0A4 NUMBER OF LIVING UNITS: NUMBER OF YEDROOMa: NUMBER OF B4PLOYEEe J Sr6f Z� ~) J CHARACTER OF SOIL TO A DEPTH OF 3 FEET-S,6:4�+/�"W.��PI (SUMP SOIL CHARA�LCT� WATER TABLE DEPTH /C> SEPTIC TANIUMEASE TRAP pTYPEMFO -AES '/t� < � 6-'—cA [faY /G � c7 NO.COMPARTMENTS L 1 WO TREATMENT PUNT ❑ DISTANCE TO NEAREST: WELL /Z FOUNDATION IO 4 PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEMI , V LEACHING LINE ❑ NO.B LENGTH OF UNEB g � 2 J Y COLI_ DISTANCE TO NEAREST:WELL FOUNDATION PFOPERiY UNE---'400 7`— FILTER{ED 11 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE C MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE r SUMPS 11 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PIOPERTY UNE DISPOSAL PONDS ❑WIDTH 1- LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PPOPERTY UNE — I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WON(WILL BE DONE IN ACCORDANCE WITH SAN JOAUUM COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WON(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPL PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOMMAN-8 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIE THE F0LL N0: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMS 18 ISSUED.I SHALL EMPLOY PERSONB SUBJECT TO WO RI(MA�PEN OF LIFORWIA.' HE APPA NT M CALL 24 HOURA IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW.SIGNED X( TITLE: DATE: PLOT PLAN(DRAW TO SCALE)SCALE Ie 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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAB SUCH AS PATIOS,DRIVEWAYS,AND WAMS. THE PROPERTY OR ADJOINING PROPERTY. J _ 0 5O AcQ�I'hi+✓ / �rt'Ee 0O icor C34P5 p 'ESoY. well ASR 2 3 199& \ 6i do kNVIgaNMFN CV Slr FOR DEPARTMENT USE ONLY /LJ�.r lCi AAP/R)�/AT.. ACCEPTED BY FJ /� _ DATE: Y AREA:� ?/SOK SUMP INSPECTIONNBB� DATE / �l AL INSPECTION BYATECOMMENTS: W P'F'12�K� (ly... -BhY(L✓�fDE,N.� ACCOUNTING ON AID# FAC# PE CODE FEEINFO AMOUNT REMITTED CHECK CASH RECOVED BY DATE SR/PERMIT NUNHIM INVOICE Z { IIh © l8