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APPLICATION FOR LIQUID WASTE PERMIT SANJOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O,BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 1209►489-3420 ROW-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED APPLICATION!6 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR>PERMIT TO CONSTRUCT.AND/OR INSTALL THE'."/OTK DCSCNBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH 6dN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 5-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DMSION. JOB ADDRESS/0R AP;�N�/},, 7��(� 0 e VAP�i i "�, )/ CRY i�OCA�• LOT SIZE 7 OWNER'S NAME b�V�L& N GTCY 1--k ' ADORE03 Al, t ll Uv "_��,, ( PHONE -; -2.7/.Y CONTRACTOR tC.tYY•LS��SG� ADDRE66_ `JwtJ �� •-SU Ln, [�A+..VUCB`4StJ�J PHONE L'?-?GV ` SUBCONTRACTOR ADDRESS UCY PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/AODITION OPSTRUCTION El ONO SEPTIC SYSTEM PERMITTED IF PUSUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDIFIOJ III TESTI.)I I NOW MANY APMwtbn S INSTALLATION WILL SERVE RESIDENCE�I COMMERCIAL I:I OTHER El NUMRGR OF UVINO UNITS: NLM MIR OFSEDROOMS:_ MISUSER OF EMPLOYERS: ii__ / CHARACTER OF SOIL TO A DEPTH O�F 3T FEET: PIT/SUMP SOIL CHARACTER: d VJ WATER TASLE DEPTH 70 / 7— SEPTIC YANI(fOREASE TRAP V-PE/MFO � CAPACITY NO.GOMPARTMFMS 7 �-�T cl PKG TREATMENT PLANT 13 INSTANCE TO NEAREST: WELL a FOUNDATION PROPERTY LINE (3 UFT STATION❑ SRE TYPE OF PUMP WAND OIL SEPARATOR IEPMLOSED SYSTEM! L LEACHING UNE NO,d LENGTH OF LINES DISTANCE TO NEAREST:WELL �_FOUNDATION PROPERTY LINE ' FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY MOUNDED 13 mar" LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE OEIII FITS gDEFTH�_SIZE a•NUI aDISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE�- 11UMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST!WELL FOUNDATION PROPERTY LINE •F I DISPOSAL PONDS ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE — I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE V40FK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQU01 COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'1 CERTIFYTHAT IN THE PERWRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,'CONTRACTOR'S HIRING OR SUBCONTRACTING ON A RE CERTIFIES THE FOLLOWING:4 CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO IWOPKMAN•S CO NSA N LAIRS OF CAUFO THE APPLICANT MUST CALL 24 HOURS RL ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. ]C SIGNED X TITLE: 11( DATE: ` 6 PLOT PLAN(DRAW TO SCALEI SCALE 'to 9.NAMES OF STREETS OR III 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 3VOTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL FXHF"NG AND PROPOSED STRUCTURES, B.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED MEAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PRDFB Y. .. .... 14� 7T �� ... .: . .. :. I ;...... . ...... .Sa 11?IINt�. TASbYAN.. 1 IZ. Lc .... f)F o 0 ..... . >...........a......:.... . ._ .. :.. <. •.... . . .. .. .........:.. ��\rl,��NUC . yT6 LL �TLyt LAJ�ti... SAGiQ 00��gIL . .. ..._._ ........ ......:............ .................:..... .. _ �13R.................. APPLICATION DATE: I C� 1l /-I- A: A 2 p II ACCEPTED 8V -4— v FOR DEPARTMENT USE ONLY f`T K„MTR BUMP INSPEC710N BY I DATB •� I &INAL INSPECTION BY 'C//>� ATE r ,/ / ADDITIONAL COMMENTS: ( /�' �+ 1 ACCOUNTING ONLY: AIDS FACS PE CODE FEE INFO AMOUNT REMITTED <jHrCXl ASH RECEIVED SY DATE SR/PERMIT NUMBER INVOICE Y 0-3 S12®41/l C�