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Post-it'Fax Note 7671 TO APPLICATION FOR LIQUID WAP _ PERMIT Co./Dept. SAN JOAQUIN COUNTY PUBLIC H. 4 SERVICES - ENVIRONMENTAL HEALTH DITfISION Phone a ,O. BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 Fax s (209) 4683420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CBmpl$t$in Triplic$t$) APPLICATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1110.3 AND THE STANDARDS{{{OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNE � Sl/ f I�nl A f \S�T�T CIT-1,�/' y�� t� f\ LOT SIZE .. OWNER'S NAME�1)1--i I D �1 i L�-�A•DDRESS 1 �j,7 " 1 F L PHONE CONTRACTOR �� V'�Cn b,I ADDRESS p (1 �n_ 1j LICs/ SUBCONTRACTOR ADDRESS UCE PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION 13� REPAIWADNTION ❑ DRTRUCTION❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDING.) PARC TUTI.1 1 1 HOW MANY APPKutlon 0 INSTALLATION WILL SERVE: RESIDENCE D3—COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITt7_L NUMBER OF BEDROOMS_ 7 NUMBER OF EMPLOYER: CHARACTER OF SOIL TO A DEPTH OFFr�3'TT FEET� _PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/ORFASE TRAP 19TYPE/MFO (: IVr r I— CAPACITY t ll/ NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL_�,c) I FOUNDATION I PROPERTY LINEi r) �— LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) /�I LEACHING LINE 13 NO.L LENGTH OF LINES �/Y DISTANCE TO NEAREST:WELL 2 FOUNDATION 730 PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 45� r1 / SEEPAGE NTS EPTH 612E _NUMBER _�DISTANCE TO NEAREST:WELLIn l FOUNDATION ur-. PROPERTY LINE -5r) 1 SUMP$ ❑WIDTH LENGTH DEPFH DISTANCE TO NEAREST:WELL_FOUNDATION PROPERTY UNE Q DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE `r\^•`l I HEREBY CERTIFY THAT 1 HAVE PREPARED THI9 APPLICATION AND TNAT THE WORK WILL BE GONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES (1V AND REGULAT IONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 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 O 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 WORK A COMPENSAT ON LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIO'N'S.. COMPLETE DRAWING BELOW. SIGNS P `/) TITLE: l.//J{�- e {�T� o DATE: �lt PLOT PLAN IDRAW TO SCALE)SCALE.'to v 1. NAMES OF STREETS OR ROADS NEAREST TO OR BO VNDING 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 P 0POSEO STRUCTURES, L. 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. BOG -7 BED i2ocj 1' ! 0/11 REC=1 I. 1 7,LL >_ ! i ; L NOV 13 1997 SAt4joAQUINCGUNTY \ rr/\rO/\�--�� yT� PUBLIC HEALTFFSERVIC"ES 'YD�G� ._..PI 15 c NVIRONMENTAL HEALTH MISIGt`i FOR OEPMTMENT USE ONLY \PPLICATION ACCEPTED BY s�/!J DATE: J / OLEO: ./ rAll(,6.R SUMP INSPECT) N BV DATE&// .A / I AL INSPECTION BV/ .�-vgATE / / `7 IDDITIONAL COMMENTS: ACCOUNTING ONLY: AID! FAC/ PE CODE FEE INFO AMOUNT REMITTED CHECKIFASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE F