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APPLICATION FOR LIQUID WASTE PERMIT L' SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIONPY P,O, BOX 388, 304 EAST WEBER AVENUE, STOCMN, CA 95201-9$8 O (209) 468.3420 � NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THI9 APPLICATION IR MADE IN COMMIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS ADDRESS/OR APNF ItJ Z y_,j -I Z G->.- C`/ - - — CITY LOT SIZE OWNER'S NAME I-�/G/U [ ��CII C�J//// ADDRESS N'/�i�V �.. �e,/OSI( J�j✓✓C 'L/ I�L/G' PLIONE ��.�' y�'<�� CONTRACTOR .� /J - T Lel / / G_5C / ADDRESSPHONE SUS CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIMADDRTION ❑ OEe TRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) P91C TESTI91 1 1 HOW MANY APNIomMen I INSTALLATION WILL aEAVE: RESIDENCE 111COMMERCIAL ❑ OTHER ❑ NUMREA OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEE!: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH �\1 SEPTIC TANK/GREASE TRAP ❑TVPE/MFG_ CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) 1 1 � LEACHING UNE ❑ NO.A LENGTH OF LINES DISTANCE TO NEAREST:WELL. FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEARERT:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAOE ATS 11DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE BLIMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE C\ I HEREBY CERTIFY THAT I 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 TILE SANJOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC)i T141S PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'9 HIRING OR 1 SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS RUBJFCT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONe. COMPLETE DRAWING BELOW. J _ _ 1 SIGNED X_ TITLE! I`" /�, DATE: 4n /Z PLOT PLAN IDRAW TO RCALEI SCALF 'to 1. NAMES OF STREETS On 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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED ARCAa anru•o�.+�� ••-••- -•-•......_ )u I.re APN)IS-1)l)J LnFIVI.9uNi RwyLPo AP,N)�I_I�)i N,.)�� ,.Nor RF2 Av oniN,.,, N 0'13'50" E 2644.9' 852.3 1792.6 ' I 1 o PUK ,LANN(C,'nlrw - PnrpN•rAq I vw I PI1 1 31 PARCEL NO. 1 �, PARCEL NO. 2 'o3 24.4± ACRES-NE-T 50.7f ACRES-NET 3 ml r � 1 ' 2 EUILD-C M'VENI ENI" I PU�LDINL 7 PJv)li-IT BM if NWC 3 N glvq eri 4PM)II-IM-q ' •P,1—BIIRDML � APq-yq eN n PN )Af-11 SEP TIC S)SfEti ��•'/ O �Ltu N,vP I UNION ROAD N 0.15'00- E 2320-2' 1 1467.8' ;' W - 9 N 0'75'00' E � NJ_,• y .. 2645 N T7 - :; 1991 ALJ � W > ORQUIN QOU I I r' a Ip 4 NTAL HEALT/ICES I FOR DEPARTMENT USE ONLY APPI-ICATION ACCEPTED BV_C / DATE: /` / .+ AREA: TANK,PIT OR SUMP INSPECTION BY DAIS / / FINAL INSPECTION BY C 1, L �c"-J I k-' DATE 5 l CI_�. /) / jI ADDITIONAL COMMENTS: //J D 6•L\ l•l.,C-d {:a�l;}i��/t i l ACCOUNTING ONLY: AID/ IZI PE CODE FEE INrO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE OR/PERMIT NUMBER INVOICE 0