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I ?LICATION FOR LIQUID WASTE PERMIT �1\ � SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES p ENVIRONMENTAL HEALTH DIVISION Il P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 466.3420 N014•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION 19 HEFIFBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTAI-L THE WOW DESCRIBED. THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/0R�`A",PHA _7.j (/qqLy' ALJ. Y1{J L.. ,1�_. �(.._� 1 /f 1 7�.1/.' ��t I. t�lUl �'-('l crry 'J l Ul..`�"1L'S`� LOT SIZE-' 'fir OWNFR'S NAME V,-k:N ;` 1'I\`��f:), ADDRESS �)'>14k,) { 1'*{ YY1V�S_.(r. v, (:` PHONE ) CONTRACTOR Lti1- ) 11\H.'�1'�!((��I (�" f 'i 111,C.. ADDRESS .>1l"� JiJ Cy 1\\4.�1, Ip l�l.r t... LIC/ y PHONEjk'1 '�• -/l/�(�1 SIIRCONTRACTO0,1' �_ i'j.11',l ' 0 1 � ADDRESS i.C- 1'S. .Cl\ylf�.'ti� ( i1f{{_. UC/Y�'C�. lIl)l')!( PHONE(I.W TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAMOADDITION ❑ DESTRUCTION ❑ [NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF SUIIDING.I PFAC TESTIwI I 1 HOW MANY ApdIAAMon f ( I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERT:IAL ❑ OTHER ❑ NIJMSER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:_ rHARACTFR of SOIL TOA DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER:_ WATER TABLE DEP7 N RFPTIC TANK/ORFARE TRAP ❑TYMIMFO CAPACITY NO.COMPARTMENTS PKO TREATMFNT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSFD SYSTEM) LEACHING UNE ❑ NO.A LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER RFD ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOL/NDED FT❑11 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE Al PAGE PITS IJ DFF-TH SIZE NUMBER -DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE RLgNPS ❑W1D711 LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROMRT'V UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HERERY CERTIFY THAT I HAVE PREPARED THIS APMICATION AND THAT THE WOW WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OROINANCES AND STATE LAWS,AND Rlll FS AND REOULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR VAIICU THIS PERMIT IS ISSUED,1 SHALL NOT EMMOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUS CONTRACTING SIGNATURE CERTIFIE9 THE FOLLOWING: ^I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOFWMAN'S COMI'FNSATION URWS OF CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNtD Xf TITLE. a'[ % I-!�1�I.Il'L-�.i DATE: ) MOT PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS On ROADS NEAREST TO OR SOUNDING 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 9YSTFM9, 1. PIMENPIONFD OUTLINES AND LQCATION OF All FXIRTING AND rr0MRtn STRIM711RFR, S. :.`JCAT{.^!:J.'L':. L8 V�il;idi PAGiUS Iii-ONE HUNDRED FIF I Y FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALIKS. THE PROPERTY OR ADJOINING PROPERTY. 'k^ WILIIOIT-DOUCLA:S TEAL ivy • a V— A1� _ . WILNOI'-00M.LAS TRACT . PAYMENT F �X/ 7 • :r - �.,� ._•_.:, ,. i SEP 4 1998 ' SAV.J01toulN I, PUeI)GiltALT11 lihJil nlvlslnl FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 1y zn- "�' / •� DATE: (�� AREA — "-- TANK, R ////��77P SPECT¢ION BY V DATE / / FINAL INSPECTION BY DATE `- ADDITIONAL COMW -- le r ,t 3 l w tt1, ., ) L 44i U ✓h 1 - 4�Iv i 30mE-- - / 4 S z��l i___��.��A��000 JJJ ACCOUNTING ONLY: AtD# FAC# PE CODE FEE INFO AMOUNT REMIT TED HECK//CASH RECEIVED BY DATE RA/PERMIT NUMBER INVOICE S 0,605 O S