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f 'f n APPLICATION FOR LIQUIEI WASTE PERMIT '4 -ANN JOAQUIN COUNTY PUBLIC HEALTh--,ERVICES ENVIRONMENTAL HEALTH DIVISION 'rT 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ^ Fy (209)468-3420 `�gO NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CempIB1B In TriplieaTBi APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. EyNWRONMENTAL HEALTH DIVISION. I JOB ADDRESSOR APN* 15300 f, 'bA'j 7(3 J CITY rp Tom+ LOT SIZE I!� OWNER'S NAME T)Vk&C� SO Ir�1`7n N.. ADDRESS t05 Lf I ` LpL L,E1MOC W�Y PHONE 6131-1 Z Ll o ` CONTRACTOR✓��NG'TTt1e CQtJfJTR'✓`C TZ0MADDRESS 1 0S''T 1 f—k ,, 04A W Rl� uc# S'A605 PHONE �3i(('(n l4{�0 SUBCONTRACTOR ., ADDRESS TYPE OF SEPTIC WORK: NEW INSTALLATION If REPAIRIADDITION ❑ DESTRUCTION ❑ _ VNO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW I I NOW MANY ., APPBo�dcn/ p INSTALLATION WILL SERVE: RESIDENCE 10 COMMERCIAL ❑ OTHER © V NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OFF�3 FEET: � W fl PI/S^ NLNU�MP SOIL CHARACTER: ,i WATER TABLE DEPTH AR7�I SEPTICTKIOREASETRAP eITYPEINIFG C4DWF, `*L CAPACITY f000 DN NO.COMPARTTMENTS �L PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL—EOL— FOUNDATION 5 1 PROPERTY LINE ! UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE NO,A LENGTH OF LINES ST DISTANCE TO NEAREST:WELL 100' FOUNDATION 15, PROPERTY UNE 5/ FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE r BEEDAOE NTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS 13 WIDTH L� LENGTH I f6l DEPTH 1?? DISTANCE TO NEAREST:WELL I l I FOUNDATION '400 PROPERTY LINE 1.0� DISPOSAL PONDS 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION 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 C AND REGULATIONS OFTHE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERT IFIESTHE FOLLOWING:'I CERT IFYTHAT IN THE PERFORMANCE OF T HEWORK FORWHICH 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 HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQURED INSPECTIONS. COMPLETE DRAWWINO BELOW, SIGNED X K�YJr,v �A0�T TITLE: Co'�ILTo� DATE: PLOT PIAN{DRAW TO SCALEI SCALE 'to I. 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 EXISTINO AND PROPOSED STRUCTURES, E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. I .. . .. 2 'IgE$ u SAN ilop'aulN'GOUNTV_ HEALY.H.SICES ., . PU013 TAL NEAL`�A[�4V1'i10N. f tiNVIRbNm is-.- - .. . ...... .. ��`�Z D I C� r. �:...... .: ... �:...... ....: }. .......:.....: .. .... . . ....... .. ....... .... ...... . . .... ... C7� �c PCS:. C a . ...... N .. .. . .... :. . ,..j;.... ZXlf 10 5w�v�PS .. .:.. ... .. ... ........ .. .. .... ��I 50 qu;k'h 122 L� .�.... . .:..... . _.... FOR DEPARTMENT USE ONLY (P— APPLICATION ACCEPTED BY DATE: I`iJ AREA: Z - 'I TANK,PIT OR SUMP INSPECTIOI4 BV DATE ! / FINAL INSPEGTION BY r BATE ! ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC* PE CODE FEE INFO AMOUNT REMIITED C— RASH RECEVPD 13V DATE SR I PERMIT NUMBER INVOICE* �O Pub,Health Serv.-Enviro,174(3196)