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"RZ 3v APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0368 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (Complaw in TriplicaH) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PEMAIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11 7�[U/n.3 AND TT//H]j STANDARDS OF SAN JVOAOUM TCOUNTY PUBLIC HEALTH SERVI ES,ENVIRONMENTAL HEALTH DIVISION. �/�,L r1 JOB ADDRESSIOR AAPPNyJ� /�� ` //"�A) �/!-/aO/~ I/ CIN �/J �JYN ''')LOTWE /;c,Pte$ OWNER'S NAJI!C: ' D/�KPS,L/ pa-i-r" ADDRESS VD/S l )p-/Yr /� �L� 02 PHONE / 9S CONTRACTORAI D19'3 `ACF�SPk (✓ /NC ADDRESS?d OdX �`J o 7-/7 DY UCF��/J�/ MONE 29'x" SUB CONTRACTOR ADDRESS UCF PHONE TYPE OF SEPTIC WORK: NEW IN&TALLATION MPAIRIADDITION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BVILDING.) PFRC TESTI*)1 1 HOW MANY Appl ..'F INSTALLATION WILL SERVE: RESIDENCE)< COMMERCIAL 13 'j EFS OTHER 13NUMBER OF LIVING UNITS: i _ NUM6l O, A-Ii7 LE F�{{BEDA00M V NUMMM OF EMKOY : CHARACTER OF SOIL TO A DEPTH OFF 3(FE"SV A PITISUMP SOIL CHARACTER: WATER TABDEPTH SEPTIC TANKIGREASE TRAP ZTYPEIMFGAC Ar'C3 CAPACITY /60a NO.COMPARTMENTS PPLO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) IFACHNO UNE NO.L LENGTH OF UNES eQ• DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH U NGT ZL-p�H {l�� DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH RAZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE n h L ' SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE Y' f� DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNF I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES C AND REGULATIONS OF THE SAN JOAGUIN COUNTY.HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOMNG:'I CERTIFYTHAT INTHE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 19ISSUED, SHALLNOT V ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOMIA.- CONTRACTOR'.HIRING OR SUB,CONTRACTD GNATURE OERTI IES T FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I$HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S MPEN ATI N LAW CALIF ilA.' THE PLICA! AUST CALL 24 HOUR IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE:01A)/"or'- DATE: P PLOT PLAN(DRAW TO SCALER SCALE 'IS (� 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. V 3. DIMENSIONED OUTUNE6 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 WALXS. THE PROPERTY OR ADJOINING PROPERTY. L }el� �vQpose� �I L___J �, Tv4.,lry �•tc rs' o c In, a3 d c rve S�jn Liv CT_� PAYMENT RECEIVED M 21995 SAN JOAQUIN COUNTY RUR).:)f,HFALTM 9ERUICES ENVIRUivN1ENlAl NEA!TH D;010N FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ' 'YYW'--'�-%` DATE: -� AREA: TANK,RT OR SUMP INSPECTION BY DATE� I II FINAL INS1l ECTION V p DATE / I ADDITIONAL COMMENTS: m Ti' t i y� '\ � 'U� re-/\7-�� 7 1 ! �• I' ACCOUNTING ONLY: Al.. FAQ PE CODE FEE INFO AMOUNT REMITTED C,14PCKICASH REC BY DATE SU I PERMIT NUMEIER INVOICE. � y