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0'- VO 2 °PLICATION FOR LIQUID WASTE PERMIT SAN `—AOUIN COUNTY PUBLIC HEALTH SER ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a (Complota In Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION 18 MADE IN COMPLIANCE"TH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER ^9-11 10.3 AND THE STANDARDS OF FFI SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTHz. i JOB ADDRESSOR APNNjI1 q 'T0200C'1/U �J N� V� /�-6, d CITY S/�- LOT SIZE"I OWNER'S NAME /tiJO jn�/ 1-G/Ye�/C/YTI.. / ADDRESS IIA? 15*114 ``AI J �drt MAI �1�ONE.� 4� CONTRACTOR .P�Ti� CJCJ� /C�r�/�DA/ ADDRESSIt-041F, �N` Si7�[t.4�779�S.�UCa7.�/7'30 -OPHONE�� SUB CONTRACTOR ADDRESS LIC; PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PMC TESTIS)( 1 HOW JIIIANY Appll eticn 15% (,� INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL U OTHER ❑ NUMBER OF UVINQ UMTS: NUMBER OOF'BEDROOMS:1 NUMBER OF EMPLOYEES:�- f_ / CHARACTER OF SOIL TO A DEPTH OF 3 FEET:_` S/`rP1T/SUMP SOIL CHARACTER: WATER TABLE DEPTH LTL/Vl SEPTIC TANK/OREASE TRAP ❑TYPEJMFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE IJFT STATION❑ SIZE TYPE OF PUMP /y SAND OIL SEPARATOR(ENCLOSED SYSTEM) f / gQIQ LEACHING LINE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE _ FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE // SEEDAOE NTS DEPTH��_SIZE 346'q NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH_ DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 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 BAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FORW"ICH \ THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON M 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 IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRANANG BELOW. 411) � UIV1 SIGNED X T TITLE: DATE: PLOT PLAN(DRAW TO SCALE)SCALE_ I.- 1. o L�/ A 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWA E DI WEED a\` 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BY B. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS D FIFTY FT.ON Y INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PRO I( \ ,FIs pm AL,gti/ SPS . J iE'ana SjE6F. ..... 0 0 .. T . r . ..... o _ C .. ; ... . _ _............ . .. . �r� u; : ...`. ... .. .:.. ............. ............. .. ...... .. .. l 1NW-UN1t _. EMACES VIA NME t Ett,,t NE?I.H _........ .. ...... FOR DEPARTMENT USE ONLY 7 �O APPLICATION ACCEPTED BY0�01- DATE: �pAREA: TANK,PIT OR SUMP INSPECTION BY ,p/� / _ / / /DATE / / FINAL INSPECTION BY q��-YT/`^ jy�'� � �T�/-�A{E '5 l •�7� l JG L� / ADDITIONAL COMMENTS/:_� !!/'(4k h"l-I �7�d [!� /Y�/ �� s�/� L//r/�`GGa /V eP.LI `}?�.5�►irvL� /Y/'�/�I L�G7Ll� /off/fit !/�ibX "7� �7/6(/L� s.-LAG 4G' U •'(. \.I a, �.,�_. Y,. �t aA K;: .� �1..�'-a-1 l�I��U //i•i�C� ce,olz--cle ! ACCOUNTING ONLY: AID/ FAC; PE CODE FEE INFO AMOUNT REMIITED CIRC ASH RECEIVED BY DATE SR/PERMIT NUMBEST INVOICE f 0760 a i Pub.Health Serv.-Enviro.174(3/96)