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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 952010388 (209)4883420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CBmplet{in Trlplk{t{) APPLICATION IS HEREBY MADE TO TME SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-'11/100.'3-AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRES6/0R APNI �OD /�J Y///[lJ/� le'o 9/� ` c" sfr' �%L LOT SIZE_ OWNER'S NAME /.7�0'</Cn� ADDRESS /✓� (�V /C .,). RHONE /'�s�fp CONTRACTOR Cv �m�/I ADDRESS_ I�--+ L`. T��;'Za UCI I RgHE YC0.J / //7 SUS CONTRACTOR ADDRESS UCI PHONE TYPE.OF SEPTIC WORK: NEW INSTALLATION❑ REPNR/ADdTION DESTRUCTION❑ _ IND SEPTIC SYSTEM PERMITTED IF MBUC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.I PERC TESTHI I I HOW MANY � APdlutlon I INSTALLATION WILL{ERNE: RESIDENCE❑ COMMERCIAL I'/ OTHER❑ NIANBFA OF—.0 UNIT.: NUMBER OF REEDROOM{: NUMBER OF EMKOYEES: V``--y� EET CHARACTER OF SOIL TO A DEPTH OF 3 F :C._fOF�/lC� qT/SUMP SOIL CHARACTER: GII WATER TABLE El. T SEPTIC TANK/OREASE TRAP ❑ K.- CAPACITY / NO.COMPARTMENTS PKG TREATMENT RANT❑ DISTANCE TO NEAREST: WELL$_ FOUNDATION�(� —FEGT,UHELIF �_ LFAC MOT UNERON❑ 61180.B IFN.T.Of LINES F�t�Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) /-- Y_7/ DISTANCE TO NEAREST:WELL FOUNDATION Z) PRD RRry LINE V fir• FILTER BEG ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTN_OEPTH DISTANCE TO NEAREST:WELL FOUNDATION PF ,—LINE / T —1—RTS LT7 DEPTH � 612E �Q NUMBER DISTANCE TO NEAREST:WELL TI'�FOUNOATION�PIbRRTY UNE � U SUMPS ❑WIDTH LENGTH DEPTH__DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS Af—CATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCE.AND STATE lAW3.AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMKOY ANY PERSON IN SUCH A MANNER A6 TO BECOME SUBJECT TO WORKMAN'.COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUB CONTRACTING SIGN�IXIFE CERTIFIER T LLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMKOY PERSONS SUBJECT TO/1 WORKMAN'.CoM�F ATII N LAWS OF FOR IA.'THE APPLICANT MUST CALL 24 HOUR{IN ADVANCE FOR ALL REQUIRED INSPECTION{,'COMKETE DRAWING BELOW. LUE' SIGNED X . �O/` TITLE! �x+s%��ti� ,r� DATE: KOT RAN IDRAW TO SCALEI SCALE So 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTPO Y. l.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PBOMSED 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, 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY U.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DNVEWAYS,AND WAUKS. THE PROPERTY OR ADJOINING PROPERTY. SAN JGA�UIN GO'J ICES PUBLIC"EALjH SET OIVI ENV IRONMEN1 AL NEA1 0 '� Q .t.4Y' • .ccS 4` TOR DEPAIITMENT USE ONLY C l/- H r APPLICATION ACCEPTED BY C I DATE: �+ AREA2 : TANK,RT OR SUMP INSPECTION SY T��,../y�/� DATE / / FIN {A/L�IN6PECTC011 BY /��Y- DATE S / ADDITIONAL COMMENTS: (•��/`-'v� \ S Ol"I ACCOUNTING ONLY AIDF FACT C- PE CODE FEE INE. AMOUNT REMITTED CHECK ASH RECEIVED BT DATE SA/PERMIT NUMBER INVOICE l W 1n F PAF Quo c 81,,l4;�vdb /-� i.s��,E6" -.seP c�-�^�a ..� u 6�•;,-e c!I,L�R.:.., b.� ��...:_ �,�,Ca-r�-*.�- �j a tl,,..., 3��""• J $h 1�`I� 20..0' .P�--� / p•k - _