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WPLICATION FOR LIQUID WASTE PERMIT (—)I_00 0 VNN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES qJ 12 .01 A63 ENVIRONMENTAL HEALTH DIVISION (00 VBOX 988, 304 EAST WEBER AVENUE:, STOCKTON, CA 95MIX88 C(D (209) 488.3420 { j NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Compute In TripReete) 4PPUCATION 18 HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,C14AAP/TER 9-111 0.3AND THE STANDARDS OFSANJOAQUIN COUNTY PUBLIC HEALTH SER�'V�IIC/EESS,ENVIRONMENTAL HEALTH DIVISION. IDS ADbRESWOR APNR n -1 / CFTY �' '` _L/OT`84ZE /✓ t )WNER'8 NAME I�` "C._A_. ( A.CC,04 S4ell L/- ADDRESS PHONE C�1J y f ;ONTRACTOR 6.k2! /�'`L' AOORESS - UCf PHONE �� / ,/ �,�y/moi�l SUR CONTRACTOR,"('A - (/j'y _ _ ADDRE88� �F'iG'LG -`I S�'4- UCf TYPE OF SEPTIC WORK; NEW INSTALLATION RFPAIRIADDITFON ❑ DESTRUCTION ❑ 1 1 177- 17 NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER M AVAILABLE WITHIN.200 FEET OF BUILDING.I PERC TESTW I I HOW MANY /-� Applladon f NSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL OTHER ❑ 1T�C- IUMBER OF NO UNITS; NUMSER OF BEDROOMS: NUMBER OF EMPLOYES: //{{ �� rr ,�,, T/ / 1 ISA JOACAJIN GOUNT', CT OF IL TOA DEPTH OF 3 FEETj-''SG�C.)CZXL PIT/SUMP IL CHARACTERLL QY ",AV � WATER TABLE DEPTH !L9� I IC F ALTH SE"CE� �u�1 �T �C�b � N HFAfTH nivl5u.11, PTIC TAN EASE TRAP ❑TYPFIMFO fJyL[_ Sw- CAPACITY NO.COMPARTMENTS TMENT PLANT❑ OISTANcE TO NEAREST: WELL Q r FOUNDATION, 7 , PROPERTY UNE Z UFT STATION❑ SIZ TYPE OF PUMP $AND OIL SEPARATOR{ENCLOSED SYSTEMI _ t t t .EACHNO DME NO.•LENGTH OF UN£B��L-lo { �`3 DISTANCE TO NEAREST:WELL { So FOUNbATIOH�PROPERTY LINE ILTFA RED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE AOUNDED WIDTH DEPTH DISTANCE TO NEAAEST�WELL FOUNDATION PROPERTY LINE EEPAOE PIT■ PTH SI SIZE �2-LI NUMBER DISTANCE TO NEAREST:WELL I t�r'iFOUNDATION 10 PROPERTY LINE ;UMPs ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE IISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE'S AND STATE LAWS,AND RULES WND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH PHIS PERMIT IS ISSUED,I BHA T PLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR >UB-CONTRACTINO SIGNAT E CEKTI tES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEPAATT 18 ISSUED,t SHALL EMPLOY PERSONS SUBJECT TO NORKM AN'6 COMP'EHS ON LAWS F CALIFORNIA.' THE APPLICANT MUST C 24 HOMtB IN ADVANCE FOR ALL REQUIRED INSP£C7lONR. COMPLETE DRAWING BELOW. ,IGNED X TITLE.: DATE: PLOT PLAN FORAW TO SCALE]SCALE 'to NAMES OF STREETS OR ROADS NEAREST T OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED !. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, I. 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 PPIOPERTY. ._ � �` ; . Ile" CkAL I 5b - . . e ..... , :. . . q 6oz� _AjFOR DEPARTMENT USE ONLY WPLICATION ACCEPTED BY DATE: -7/In REA: 'ANK,PIT OR SUMP INSPECTION BY DATE 1 ( FINAL INSPECTION BY r TE 1 1 py IODITIONAL COMMENTS: T '� ACCOUNTMO ONLY: AIDR FACE PE CODE FEE INFO AMOUNT REMITTED CHECK#ICASH REC - Y TF SR I PERMIT NUNISER INVOICE IF z 0� ] s-6_31