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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 12091 4683420 NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11103 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. J JOB ADDRESS/OR APN# l q 7(i /11 U % V��" /IGT/I U �7 CT/T/VJ 4�1- / oA LOT SIZE OWNER'S NAME /I ,)'m /Zll7'4Oi..') ;/r� ADDRESS /��Ll(,) f' ,3L"J 1/.:/ /k/J RHONE /7 � CONTRACTOR 4,0� 4O/,,.}/ '21 1771 L ADDRESS / LIC# RHONE SUBCONTRACTOR/ILL,/� ��1%/""/�J'Ee{{-�IiA/S ADDRESS !_SJ'-/ A/fA N tS�/ �J LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION{.y REPAIR/ADDITION ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMrREO IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PE RC TESTI.)(1 HOW MANY y1 J �J / APPBoetlon/ INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL OTHER 111`;V/N//f//G/%--i NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEE/: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: N✓r. nnRTISUMP SOIL CHARACTER: L WATER TABLE DEPTH SEPTIC TANK/GRFASF TRAP P.TY'PE/MFG It>k�: f;,;�!�'J CAPACITY / ' 1�/i/ NO.COMPARTMENTS PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑rSSIIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) _) LEACHING LINE W NO.A,LENGTH OF LINES �3 J(�)��f DISTANCE TO NEAREST:WELL 3 I�+l FOV /�'�T/�PROPFRTV UNE �JU/r FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH 912E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMP$ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I 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 SAN JOAQUIN COUNTY.HOME OWNEROR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFYTHAT IN THE PERFORMANCE Of THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN 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,I SHALL EMPLOY PERSONS SUBJECT TO WOWMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$. COMPLETE DRAWING BELOW. � rte- 6,k-4- y / SIGNED X �i L'H'(, ,?//,�,QJ TITLE: 6!/,k-4=7C(/ DATE: RIOT PAN(DRAW TO SCALE)SCALE 'tP 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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. j- o K Lot�bn" p 5 I 311 JUN 2 4 3998 '.. SAN JUAQuII,;c;(,,,I .PUOLlO.HE:ALTH.SEF14)C .. ENVISOtJMENTALHFAiTH pNl., I FOR DEPARTMENT USE ONLY X71 APPLICATION ACCEPTED BY C7�- ��,'..f 1/�(k -_-_.-.f DATE: C IC AREA: Z.l IC TANK,RT OR SUMP INSPECTION BY J DATE I / FINAL INSPECTION BY DATE / L" / ADDITIONAL COMMENTS: T Yk, ` l✓ !w./l 1 AC i-HCS.- % R(i S>> /4tiC�S1._ 17. ACCOUNTING ONLY: AID# FACI ��lk� PECODE FEE INFO AMOUNT REMITTEDNECK# ASH RECOVED BY DATE 99/PONMT NUMBER INVOICE/ Gay FY /6,i' 11