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Al APPLICATION FOR LIQUID WASTE PERMIT —AN JOAQUIN G�UNTY PUBLIC HEEALTh SERVICES ENVIRONMEENT 304 EAST WEBER Al (209)ass 3410, ROH-REFUNDABLE PERMIT EXPIRES 1 YEAR (Cimplets in TTiplkits) �' " APPLICATION le HEREBY MAGE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSIOR APNI ,y' J L611i t2LEE Iq CITY pr' I V/ LOT S1ZE M A►v��A , OWNER'S NAME i jUi -74407 f-2Qj4 L._ ADDRESS CONTRACTOR,e �S/7F" iV.r ADDRESS - 2 LIC)./ 1 PHONE,4!r�-_ SUBCONTRACTOR ADDRESS LICK PHONE II TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIRIADDITION DESTRUCTION 0 r ING SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 15 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI*I 1 1 HOW MANY ri AppSwtlan 0 INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER �,�.J�E'f NIIl.L �La�� NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: - CHARACTER OF SOIL TO A DEPTH OF 3 FEET:6 A 1rIr-) -PIT/SUMP SOIL CHARACTER:. ,-5,a/�L7_WATER TABLE DEPTH 2 i SEPTIC TANKIOREASE TRA--PII 0TYPENFOG_SL:�C- -`'T' _CAPACITY / i NO.COMPARTMENTS 11 PKO TREATMENT PLANT t_I DISTANCE TO NEAREST: WELL FOUNDAT11w PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) "-• '.k.'.' .i�; LEACHING LIME 13NO.6 LENGTH OF LINES DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE qTS ❑DEPTH 812E NUMBER DIST l2 7&JEJIREST-WELL FOUNDATION PROPERTY LINE BUMPS WIDTH LENGTH Y -�T DEPTH '� 1 &;ANNCCLE'TO NEAREST-WELL FOUNDATION,R"pJ / PROPERTYLINE _f I DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL - FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OFTHE SAN JOAGUIN COUNTY.HOME OWNER OR LICENSED AGENT'B SIGNATURE CERTIFIE8THE FOLLOWING:•1 CERTIPYTHAT INTHEPERFORMANCE 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 CAUPORNIA.• CONTRACTOR'S HIRING OA I SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T1418 PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. r le SIGNED X '� ! / 'o TITLE: 1 �= ...__ DATE:. _ PLOT PLAN(DRAW TO SCALE)SCALE 't° 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. O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. 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. ` f .. I. . A .. 998 .. ....... :.,.. 1 ..,.,.. . i .. /�- aq f ro rF)'4 .. k Ir y .� .. pa Q .... 1 ... .. .�5� I. '.,. O ..I-.- O .. ..,N LL SG ' i p I y� j... ., .... p d - 71 E r i I� .... ..... WC L I ' Q IJ I 5 :. 3 as y ® FOR DEPARTMENT USE ONLY ' APPLICATION ACCfR'TEbBY / / �- �q DATE: REA:��N/`" TANK,PIT OR SUMP INSPECTIONMLI2 BV _-DATE ! 1 f iNAL INSPECTION BY f>r L 1 !I SLP ADDITIONAL COMMENTS: )14A) N E. _. m k + �/ {f ."'-. f"Cf _ �Y 12W.. � !�^ / �I_/1l"�T / t ACCOUNRIkG OkLY: IJUI FACS jy� : :. 4-7 PE CODE FEE INFO AMOUNT AEN1ITED G IEC CASH RECEIVED BY DATE,.: SR I PERMIT NUMBER INVOICE/ I? p _ lK T) D Pub.Health Serv.-Enviro.174(3196) r