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APPLICATION FOR LIQUID WASTE PERMIT DA u-AN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES' r ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201.388 (209) 4883420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O-pn 1 / Q (Complete in Triplicate) / I .J APPLICATION IB(HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION In MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1110.3 AND THE STANDARDS OFF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER.ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESS/OR APN# L Z J O �"'� `� / CITY �� U LOT mZE ' OWNER'S NAME__./ r- An ADDRESS p 3 PHONE ( l CONTRACTOR _gy /Ip/Csq+� p ."r 60 S4,..(.! ADDRESS L�U L-I f'R i�/✓+ C HJ .�� LMB J �J PHONE `"O /S I J J I BUB CONTRACTOR ADDRESS LICI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ AIMMAJADDITION DESTRUCTION ❑ ONO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) P91C TuTIe1 11Y}BlW�MANTC APPFHrSonB A//! �I^�I VVI P1\�J� INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF S�LO MM S' NUF9AUG OF EMPOYESS: 0 2 2001 CHARACTER OF BOIL TO A DEPTH OF 3 FEET: q� PFT/BUMP SOIL CHARACTER: WATER TABLE DEPTH 14l lT 0 SEPTIC TANIIDRSASE TRAP ❑TYPEMFO CAPACITY NO.COMPARTMENT{AN InA 0111\I(`('1 !.TY MO TREATMENT HINT ❑ O STANCE TO NEM6ST: WELL FOUNDATION PROPERTY LINPUBLIC HEAL111 SFRVICES -- �;,�.I Hi null -,Ivl n j LIFT STATION❑ S1ZE TYPE OF PUMP �\\ SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING UNE Y,7 NO.a LENGTH OF LINES / —LlV DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE -enl J R FILTER FED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY,UNE MOUNDED ❑MOTIH LENGTH( DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PIT& ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS 0 WIDTH .7 LENGTH 3 L. DEPT11=DISTANCE TO NEAREST:WELL /CA-) FOUNDATION PROPERTY'UNE eJ DISPOSAL"NOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION POPERTY UNE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WLLL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS Of THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOFNT'S SIGNATURE CERTIFIES THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF TIIE WOO(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 BUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISBUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOUII I IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BBELOW. SIGNED X O /L�- TITLE: C-- DATE, a PLOT PAN(ORAW TO SCALE)SCALE m I, NAMES OF STREETS OR ROAD6 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 PATIO$.DRIVEWAYS.AND WALKS, THE PROPERTY OR ADJOINING PROPERTY. Vc �' r (/ S J1 L�1 �'JVVV}AV1/..1Iy l\y7'., L('t - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTE BY GG DATE: rf AREA219 TANK,RT OR BUMP INSPECTION L DATR �FINAL INSCTION DAT ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID/ FAC# PF CODE FEEINFO I AMOUNT REMITTED CHECNI AFH I RECEIVED FY DATE M I PERMIT NUMBER INVOICE B 2 Z 197-,?-/o ,