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APPLICATION FOR LIQUID WASTE PERMIT SAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES- ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKMN, CA 95201 88 (209) 468.3420 11011-REFUNDABLE PERMIT EXPIRES-1 YEAR FROM DATE ISSUED r24 c!5 --V�0 — 0-7 (Complete in Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TTTLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEAL N DIV) ��r, •/��.y /yyy �J �J/f`/ /� f JOB ADDRES81OR APNfid CITY e) ' . r LOT SIZE RF Q OWNER'SNAME �L.C/� r / b/J �ADDREee Q v _. 1J- PHONE CONTRACTOR � ^(J.C. L •f�ADDRESS...,� LICI�PHONE SUB CONTRACTOR ADDRESS LICK PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION Or REPAIRIADDITION ❑ DESTRUCTION ❑ ING SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEiC TESTIO 1 1 HOW MANY AppBoatlon 0 INSTALLATION WILL SERVE: RESIDENCE 9 COMMERCIAL ❑ OTHER❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES; CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITIBUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP P TYPEIMFG__ R 4-l-, CAPACrry NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST; WELL�eSIJ � -4- FOUNDATION �� PROPERTY LINE �r"'� /�"T- UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR{ENCLOSED SYSTEM( ,.�., LFJLCHNG UNE K NO.At LENGTH OP LINES —�n n If 7 DISTANCE TO NEAREST:WELL PO NU DATION ja` PROPERTY UNE c C1, f / FILTER DED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE �t NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE / SUMP& WIDTH LENGTH ��/ DEPTH,DISTANCE TO NEAREST:WELL FOUNDATION ZO PROPERTY LINEr - DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION -PROPERTY UNE 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 AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOMEOWNERORLICENSEDAGENT'SSIGNATURECERTIFIESTHEFOLLOWING:'ICERTIFYTHATINTHEPERFORMANCEOFTHEWORKPORWHICH 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 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIONLAWSOF CALIFORNIA.* THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. {/ J SIGNED xSO�� _�_rl..r� TITLE:. / DATE: r�r_' G/ PLOT PLAN)DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR LOADS 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, 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. ... :.. ....................:, - ...;...,.i... .,..i... ........... .. .. .. .. ...,.. ., -.,. ., .. - .. .. -.. ... �;.. . o V o. ... .. .. .. '. :. 1 .,.. - � .................. b .................... I�-�r ........ .. z. , �- T js L. .. .. .. .... .... .. .. .. .. .. .. _ .. .. .. .. PFl,YNi E l :. RE EJVE-J�`� . .... PiJSLI�HcAI_TH c�R,�tEr� ... ..; . .:. .. :. .. ., ., .. .....lJ{.. ... .... FOR DEPARTMENT USE ONLY f /j APPLICATION ACCEPTED BYpj- L; DATE: '°"� AREA: Z TANK,PIT OR SUMP INSPECTION BY DATE �1`:7 FINAL INSPECTIO BY DATE-7 ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID/ FACT' - 1" PE CODEFEE INFO AMOUNT REMITTED HECK) ASH RECEIVED 8Y DATE &R J PERMIT NUMBER INVOICE• 74 I �Sa ' 9. ; -1 plc,;' U �W