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APPLICATION FOR LIQUID WASTE PERMIT 9AN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIONS�p P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 ,. (209) 488.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS 'tOF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. `_7`i JOB ADDRESS/OR APNN i QQ_ EA S I I r T 1-1 V!1/j Z!) CITY//--�� 1'�AN T F-c A LOT^�SIZE�L, OWNER'S NAME ��N R l5 T'-1 EA D R-I C IL-- ADDRESS Q�_ ✓�. 13 O)c I2 4�Z_ OR K D A LIC r.AN • PHONE CONTRACTOR S L.F ADDRESS S e4M e�, LIC# PHONE 2 01 V63cl SUB CONTRACTOR ADDRESS UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(al I 1 HOW MANY APdioatlon l INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL I�, OTHER 11 &/zw NUMBER OF UVINO UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: -S CHARACTER OF SOIL TO A DEPTH OFF3{ /FEET: 7_ A�*, PIT/SUMP SOIL CHARACTER: �4f M� WATER TABLE DEPTH 3 0 � SEPTIC TANK/GREASE TRAP 9-TYPE/MFG / F L e CAPACITY 0210 NO.COMPARTMENTS PKG TREATMENT PLANT q DISTANCE TO NEAREST: WELL fly0 FOUNDATION_ 6' PROPERTY UNE '30 � UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE NO.&LENGTH OF LINES 2- / vc> I DISTANCE TO NEAREST:WELL G FOUNDATION15�t ePROPERTY UNE 3S FILTER BED WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMP& ❑WIDTH Z LENGTH DEPTH I0� DISTANCE TO NEAREST:WELL 13o / FOUNDATION 2 G h PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 1 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.HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE 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 CAUFORNIA.- CONTRACTOR'S HIRING OR 1 SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I 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. SIGNED X r...lf�'�yc'-G�'� TITLE! C-,eyDATE: Z t PLOT PLAN(DRAW TO SCALE)SCALE "to 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. 3. DIMENSIONED OUTLINES 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 WALKS. THE PROPERTY OR ADJOINING PROPERTY. :....... .: :. ..... .. .. .. .. .. .. w y . t , ._ .. 4 ..... . _ a Y .. tU .. M ..... ...... .. . .. $c>oo G"4 0 Y _T / G EST xoo IAS. x ;. 166 °`EA GN GNC H .. {{" i LV 2.'k lb.x 10.. ....... ...... .... 1G.1 Ct ►'.` ;.....' .. p n ...... ........ N.. .. ri 3 1 fSaGL . .. .. _ L ..: 0 5 "T .. F. A 1,1 Q cfid" .... : ...... . . ............. .. .; .. .. .4 199E. . . . z . _ ii HEkL4r it E A -S T S.%` k''T Gv :>� ! :Z O N)4 h1 "v rS,,, �1 Z. FOR DEPARTMENT USE ONLY N / 0307 APPLICATION ACCEPTED BV DATE: ( L�V AREA: OT TANK,PIT OR SUMP INSPECTION BY /� ,..tom I NSPE� �E-�D�,�E-3�y�T�NFINAL INSPECTION BY DATE I / ADDITIONAL COMMENTS: Axa ACCOUNTING ONLY: AID# FAC# /0 PE CODE FEE INFO AMOUNT REMITTED C C SH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE# Vasa d3� (. �/�� l I '`� 7,2 / 7-'/5 ;2�