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'ost-it"Fax Note 7671 APPLICP--^N FOR LIQUID WASTE PERMIT SAN'JOAOL JUNTY PUBLIC HEALTH SERVICES �Bf 'dept. (3G'i/t/ ENVIRTNMENTAL HEALTH DIVISION hone x ,O. BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201 388 1 - 355 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compl&te in TriplieltQ APPUCATION 16 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 9-1110.3 AND THE STANDARDS DF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. r ADDRESS/OR A\PN/ � ] / I nw\G DD `SA-E f� CITY LOT SIZE ER'S NAME�)) !n`J`VA IF ADDRESS R �• l J PHONE ITI CONTRACTOLt-h� -1_L �G •`LADDRESS__ I �Q I I>`n%�UC/ PHONE- CONTRACTOR •••7 ADDRESS +J-`a•'�UC/ PHONE 1-PSE OF SEPTIC WORK: NEW INSTALLATION ERS REPAIR/ADDITION ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.( PIERC TESTI.(I I NOW MANY ApNlwd-/ I ALLATION WILL SERVE: RESIDENCE 01—COMMERCIAL❑ OTHER❑ I .:BER OF UVINO UNITS: I NUMBER OF IEDROOM&::_NUMBER OF EMPLOYEES. CHARACTER OF SOIL TO A DEPTH OFF3T FEET: L( q-,/ PR/Sump SOIL CHARACTER: WATER TABLE DEPTH �+TI FC TANK/GD IIEASF TRAP -rYPE/MFO C_(T)I.�C II-I= CAPACITY 1 )l J� NO.COMPARTMENTS_� I TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL I FOUNDATION�� PROPERTY LINE I nn LIFT .FACHNO STATION❑ SSIZUNE =D L LENGTH OF TYPE INEB F �PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) ,,y++��Y I/^'�)1 \/ DISTANCE TO NEAREST:WELL FOUNDATION 73 V PROPERry UNE ILTER BED ❑WIDTH LENGTHDEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I NDED 1❑r�3,__WID/IDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE c 'ADE PIT& LTDEPTH3`lf�_WE4;e_NUMBER_Ll DISTANCE TO NEAREST:WELL FOUNDATIONur.. I P"OPERTY UNE ]n :R1rAp8 ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE Q ASPOSAL PONDS 11 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE �•1 IEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES I N REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH +PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO M WMAN-S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR O IUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO VOWO�AR COMPENSAT ON LAWS OF CALIFORNIA.- THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$. COMPLETE DRAWING BELOW.. TrTLE: NI✓l 2 DATE: _ PAT PLAN[DRAW TO SCALE)SCALE IO NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED -'JTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. MENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELL$WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON LUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. v4 7 L'BEb f2oa Ito � f `o is Ill/ a ��D/ rill 7t5 PIAYMEN � lN'RECEIVETD NOV 13 1997 SANJOAQUINNRCiOUNTY .. ,rtC' J- PUBUC HEALTH'SERVICES 7 a)Q'5 PI `;.1 S ENVIAONMEPITAL HEALTH 6NISIi W FOR DEPARTMENT USE ONLY ^� :ATION ACCEPTED BY >/NJ DATE: I �� A�REA: /^)/_/' NK, T 1R SUMP INSPECT( N BY l�/I� DATE // .// / ! AL INSPECTION BY/ a-,- 1ATE4 ONAL COMMENTS: ACCOUNTING ONLY: ARO! FACT :ODE FEEINFO AMOUNT REMITTED CHEC K/QCA6H RECEIVED BY DATE &R/PEWIT NUMBER INVOICE/