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aw APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 952010388 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (DBmPIBM in Trgikabol APPLICATION 18 HEREBY MADE TO THE SAN JOA RUIN COUNTY MR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.`CHAAPPTTE�R 9-1111110`.3'ANDTHE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEERV�LC,EESS,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APNAA I L I JeLA' nV1 1«��✓ CRY �TG'4/'CIi'/Y `-I?• LOT SIZE 7SXIZS ALLEN C ARVEN p CWNER'6 NAME I' r,_E�, ADDRESS LL��FI fL�I. /� RIONt Y/«/I 7SZTln CONTRACTOR F7pR `!�'.I S /'!D/�� ADDREss�99�N• WIL 50N WA ;/uc✓V S43/T� SUBCONTRACTOR ADDRESS lIOI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRADDITION D"TRUCTION ❑ (NO SEW IC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING) PMO TEST(s)1 1 HOW MANY ApNloetlon I INSTALLATION WILL BMW RESIDENCE ICL F../ COMMERCIAL 13OTHER 13 NUMBER OF DVINO UNITS:/ NNA861 OF BEDROOM{: � NU M OF EMPLOYEES: T / CHARACTER OF SOIL TO A DEPTH OF 3 FEET:AL )Q3E RT/SUMP WIL CHARACTER: WATER TABLE DEPTH 7 S SEPTIC TANKIOREA6E TRAPQD TVPEMPO P�T/}QJOL VALl- CAPACITY /525b i NO.COMPARTMENTS Z FIRM TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION FIOPERTY LINE LIFT STATION❑ SIZE TYPE OF RUMP / +SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACMNO LINE M NO.i LENGTH OF LINES 'L -- S 3 L "G DISTANCE TO NEAREST:WELL N FOUNDATIO _PROPERTY LINE 5" S FILTER BED 11 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION P OMPTY LINE MOUNDED ❑WIDTH LENGTH'(rf DEPTH DISTANCE TO NEAREST:WELL_FOUNDATION PROPERTY LINE B®ADE RTI XDEPrH E SIZE TCf I NUMBER DISTANCE TO NEAREST:WELL FOUNDATION � PROPERTYLINE SUMPS ❑WIDTH LENGTH DEK14 DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE y DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:V/ELL ED...ATBIN PROPERTY UNE ro\ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APRUCATKIN ANO THAT THE WORK VALL 8E DONE IN ACCORDANCE WITN BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND BOLLS AND REGULATIONS OF THE SAN JOAQUINCOUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH t 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 HIRMG OR TS r SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•I 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 CALIFORM THE APPLICANT MUST CALL 24 IOIUIIB IN ADVANCE POR ALL IIEOMRED INSPECTIONS. COMPLETE DRAWING BELOW. ^� N C SmNEO /�KY1'/:t/ � �9T.RC-(/ � TITLE: GATE:aJ•�- � ! 6 ' PLOT PLAN(DRAW TO SCALE)SCALE •I. 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 OUT(IVES 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 WAIXB: THE PROPERTY OR ADJOINING PROPERTY. I • I IP.L\ .1 R I 1 t : IOEll. 3c' I I s -covet I : I f i I, w• {.. , I i L 4bv 'W,N. i 3i �B iE IDI jI N Fri -- U I2?LEAdH♦ - (. . IQI ILII LSi E 2 GkhvG I ,_ LL W M�N r?e0 ehaenrld LI Ke Nae s! tw� L En I. I Ek)GJt' L 1 CN � I I I r - I L i jrc y E I I do D j I MAY 2 9 1996 �NVIH D.APARRISN i S0118,ItC., BmaaN PUBLIC HEAL,H SL gVII ES S'"5'Y/ CNMENTAL HEALTH L VISION /� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY S N DATE: Pc� AREA: ZJLS TANK.PIT ON SUMP INSPECTION BY v DATE / / FINAL INSPECTION BY ,r I p 1 / ATE 96I ADDITIONAL COMMENTS: S-31-°l� NLrf /'-e« �F3.¢-E-C! :� IAC U rCGCJ 4- Ye U�-$ ev, IUo"o'jE' 30MIn1acf LaO - coc7E1jMR 03 ACCOUNTING ONLY'. AID/ FAC. R CODE FEE I AMOUNT REMITTED HEC ICAAN BVg RECEIVED BY DATE BR I PT NUM.- INVOICE(1� O O d l ,