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APPLICATION FOR LIQUID WASTE PERMIT PAYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEI\/EE ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 OCT 2 4 2000 (209) 468-3420 SAN JGAUUIN COUNTY NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED PUBLIC HEALTH SERVICES IComplste in Triplicate) ENVIRONPAENTA, HEA!TH O ISION APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-11 10.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR A'Nir 1,4-107- 1,4-1O'Z 70y�-" Co L.O IJy 9`0• crry L.C7D= LOT SIZE 'j PX re.'j OWNER'SNAME J-i-GNCites T(OY ADDRESS c �cIpCY�LG ,�,1 �T -75q59 Q p PHONE 931- 3z�b CONTRACTOR (1A[�U@?.fpct� {' ��v vl �-N� ADDRESS (O J O 67, fm(z�)J W-D, LIC, 75 1 59 0 PHONE 309'2552 SUB CONTRACTOR ADDRESS LIC I PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION IRL DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WITHIN TOO FEET OF BUILDING.) PERC TEST(.)1 1 HOW MANY App{io tion s INSTALLATION WILL SERVE: RESIDENCE®. COMMEIICIAL ❑ �J OTHER ❑ NUMBER OF LIVING UNITS:_ NUMBER OF JAN" .' NUMBER OF EPAPLOYEEE: C�-� CHARACTER OF SOIL TO A DEPTH OF 3 FEET: 1i-N" PkN PITISUMP SOIL CHARACTER:W I41110,f-RN� WATER TABLE DEPTH _SEPTIC TANKIOREASE TRAP ❑TYPE/MFG LsY-'R`pT 1►JCa CAPACITY I,Y�0 G Qk�N`7 NO.COMPARTMENTS PKG TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL o FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) ��11 LEACHINO UNE ® NO.A LENGTH OF UNES I - SD DISTANCE TO NEAREST:WELL 950' FOUNDATION -1 a' PROPERTY UNE ZO / FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS DEPTH ZS/ 812E 3 F NUMBER I DISTANCE TO NEAREST:WELL D�Y FOUNDATION PROPERTY UNE S SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL IFOUNDATION PROPERTY UNE DISPOSAL PONOS ❑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 AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHK:H THIS PERMIT 18 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS `OOFFCCALJFORN-IA THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. -SIGNED X l J" "'�T TITLE: DATE: 1 c)'Z� d o, PLOT PAN(DRAW TO SCALE)SCALE_ `Io 1. 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 OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADRIS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ..... ..i...... .. ...... _... .. .:.... .. .. .. .. .. ............. 11 B L7 _ fgd ell So LIC tv;7L � . . L .. _. .. _ . .