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APPLICI FOR LIQUID WASTE PERMIT SAN JOAQUIr%PzOUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICBmplatB IR Trpli-Hil APPLICATION IB HEREBY MADE TO THE BAN JOAOUIN COUNTY FCR A PERMIT TO CONSTRUCT ANDNR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1110.3 AND THE STTANDA�RDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH BERRVICE8.ENVIRON/MENTAL HEALTH DMSION. JOB ADM6810FI APN, M//f�c-L/ A O 1\ /"/L-) /-,0 . CRY / 1 LI ,�-/ LOT BIZ' �o UWNER'S NAMElr�gcY(ZADDRESS I �I / PHONE J •'� �/(''' CONTRACTOR 1�/�j'T'yI-'I.L EIl(ifux/' ADDRESS /L-1,) /1 ALU GI^ LIC, //3t1 7J 3 PHONE SUB CONTRACTOR ADDRESS UC, RHONF TYPE OF SEPTIC WORK: MEW INSTALLATION 0 REPAIRI—TION iE DESTRUCTION IND SEPTIC SYSTEM PERMITTED IF PVBUC SELVER IS AVAILABLE WITHIN 200 FEET OF BUILDING., FERC TESTIN I I HOW MANY ft—d-, INSTALLATION WILL SERVE: RESIDENCE ID COMMERCIAL 0 OTHER 0 NUMBER OF LIVING UNITE:_NUMBER OF BEDROOMS NLMam OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET:/ / PIT/SUMP-/SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKJOREASE TRAP 01 TYFEJMFO , 4 C t", ,C rC T 4- CAPACITY /"7 C1J GC.�I I�-) NO.COMPARTMENTS PKO TREATMENT RANT 0 DISTANCE TO NEAREST: WELL 106 FOUNDATION PROPERTY UNE LFT STATION❑ S1ZE TYPE OF PUMP SAND OIL SEPARATOR[ENCLOSED SYSTEM) I LEACHING LINE © NO.S LENGTH OF UNEB I - :�()I DISTANCE TO NEAREST:WELL�7'FOVNOATION_ PROPERTY UNE L fJ FILTER BED 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE NTE 0 DEPTH SIZE NUMBER INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 6-11; 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION POPEtTY UNE DI6POBAL PONOS 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION POPERIY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COLI ORDINANCES AND STATE LAWS.AND RULES AND REOUI AT IONB OF TINE SAN JOAGUIN COUNTY.HOME OWNER OR UCEN8ED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY T MAT IN THE PERFORMANCE OF THE WORK FOR VAHIOH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WOR(MAN'B COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING DR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR W/11CH THIS PERMIT to IBBLI 1 SHALL EMPLOY PERSONS SUBJECT TO ' WORKMAN'8 COMPEN8ATION W8 OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED /IN,B.P.ECTIONS. COMPLETE DRAWING BELOW. 5 X SIGNED X TITLE: �l lr^��1 DATE: PLOT PLAN(DRAW TO SCALE)SCALE_ 1,NAMEB OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWARE DISPOSAL SYSTEM OR PROPOSED 2.OUT UNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUT U NES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLIT S WHIN RADN6 OF ONE HUNDRED FIFTY FT.ON I NCLVDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALXS. THE PROPERTY OR ADJOINING PROPERTY. k. 1 > 'A �a 111 ,J r 3 W'A IENI'.., MAR 1 7 1998 TY I'_'Ii:,G 4ILAI'!H 5i�'•�4/[CES :NvlHnl I!`APJ7nL HEALTH DIVISI FOR T DEVAPMEHT USE ONLY MTLICATION ACCEPTED BVs� L_'.�,C 'T'tX..�- _ DATE' .� AREA.-)IF TANK,PT OR BUMP INSPECTION 8V DATE�I I FINrL INSPECTION BV DATE I / XDDITIONALCOMMENTS: I r I I ACCOUNTING ONLY: AIRF FAC/ PE CODE FEE INTO AMOUNT REM,ITED ITEC (CASH RECEIVED BY DATE BR/PE!"T N1.I141291 INVOICE If PUb.Health Se--Enviro.174(3196)