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_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 952010388 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED (Complete in Trpliate) 1PPLICATIGN IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDPOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAGUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11,30.3 ANND�THE STANDARDSOF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. l 'OB ADDRESS/OR APN1Y I 1 6� E &e-,e MVS /�IG�TTI�tIJV CNY Ar-lfa 'YWCI .SLOT WE1t`^��✓I)�� _IWNER'S NAME � 4"e-Y 7pItO ADDRESS �FR+�'F / _I PHONE CONTRACTOR 6-32. J CADDRESB 11Ci A!b�a-1 PHONE :UB CONTRACTOR ADDRESS UC! RHONE TYPE OF SEPTIC WORK: NEW INSTALLATION 19 REPAINADDITION ❑ DEBTLUCTION ❑ NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI)1 1 HOW MANY APPloetlon l INSTALLATION WILL SERVE: RESIDENCE ® COMMERCIAL ❑y� OTHER ❑ NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: l NUMBER OF EMPOYEEB: HARACTER OF SOIL TO A DEPTH OF 3 FEET: (21 LAM PTISUMP SOIL CHARACTER: OJW .Ji lhij WATER TABLE DEPTH er J( •_ .-EPTIC TANIGMEASE TRAP ®TVPEMFG C!JPLG I ill PC, CAPA TTY 'E,e C= NO.COMPARTMENTS cel+ r PIG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL 1c1/J t FOUNDATION -NU I PROPERTY UNE V� UFT STATION❑ WE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) I a EACNNO UNE E3 NO.i LENGTH OF LINED?] x L46 F DISTANCE TO NEAREST:WELL �'C)I FOUNDATION i4r)t PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE •10UNDED r❑n WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE P EEPAOE TS 1S DEPTH WE Ail II NUMBER ( DISTANCE TO NEAREST:WELL XY FOUNDATION,PROPERTY UNE 'SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I 1 DISPOSAL PONDS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES 'TND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOMNG:'I CERTIFYTHAT IN THE PERFORMANCE OF THEWORK 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.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO /OPKMAN'S COMPENS N LAWS OF UFOFNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION%. COMPETE DRAWING BELOW. / {I/ �1 y� / DATE: SIGNEOX /l.Jy�, f.[l TITLE; (7fi-K�/f lca�'FL �+CJ'1T PLOT PAN IDRAW TO SCALE)SCALE _. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED \ 2. OUTLINE OF THE ROPEFT'.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. A 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED MEAS SUCH AS PATIOS,DRIVEWAYS,AND WAUKS. THE PROPERTY OR ADJOINING PROPERTY. J1 �( p - - II _ _app II 0 ...........