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y REPLICATION FOR LIQUID WASTE PERMIT >� Y SAN JOAQUIN COUNTY PUBLIC HEALTH SEFiVPCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)458-3420 110111-AEFUNOAi3lE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CompNtn in Mpliests) P APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAOUIN COUNTY DEVELOPMENT TrrFLE.CHAPTER 0-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUSUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOS ADDRESSIOR API! / 7 E7V CITY 1' LOT SIZE OWNER'S NAME, S lCS lJ�•'✓ _ADDRESS / , f PHONE CONTRACTOR ! '�� '"" ^ ADORESS / U Me-/2 L. t .�� UC! l� PNONEy SUB CONTRACTOR ADORfeB LRC! PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAwAODTION ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERFAITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.I - PERC TESTm t I NOW MANY Applmden 0 INSTALLATION WILL BONE: RESIDENCE 0 COMMERCIAL IR OTHER ❑ '.r �� NUMSER OF LIVING UNITS: NUMBBI OF BEDROOMS: NUMBER OF EMPLOYEEII: CHARACTER OF SOIL TO A DEPTH OFI�33 FEET: L PITIBUMP SOIL CHARACTER• /IP-'WATER TABLE DEPTH SEPTIC TANKIOHEASE TRAP OGTYPEIMFO I NC.rt.-1 < CAPACITY -20a NO.COMPARTMENTS PKO TREATMENT RANT❑ INSTANCE TO NEAREST: WELL .10.rl 1 FOUNDATKIN - PROPERTY LINE �1 LIFT STATION❑ 6'IZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMA e LFAC14HO UNE 0 No.a LENGTH OF LINES In r DISTANCE TO NEAREST:WELL 100 -r FOUNDATRo _PROUNE�� 11— PERTY FILTER MED i ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH_LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PITS l'uEPTH '7,,^SIZE 3 16 —NUMBER_DISTANCE TO NEAREST:WELL,/.�FOUNDATION��PROPERTY LINE 2-CQ - SUMPS 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS LI%MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY ONE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:`ICFIMFY THAT WTHE PERFORMANCE OF THE WWORKfOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'$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 RS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X ... - TITLE: —DATE:—/(? PLOT PLAN(DRAW TO SCALE)SCALE '1e 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DEPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.-DtpT&stoNED OUrLWES AND LOCATION OF ALL EXISTINO AND PROPOSED STRUCTURES, 6. 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. zj Prf3�x �L25 k .. .. ,p . . .... .. 70 _ ..... _ rMJ . V�RJ _.. .. . . : i � : �(-_ - :.. .. .� 1 : %� : t -C�{ r?uucxTris��ri"nc�s ..: C I `7 1'11-- I � ENVIRONMENTAL HloAL7M{71VIS10N ... .. \� ..:...... .. .............. ...V, .. L... .. .....: . „I f.... ...: ... f L I I'.. ., :... ........., ,t.. � f 3 �. `�' .. :... .. ... � x — TMENT USE ONLY APPLICATION ACCEPrm BY c t �ARDATE: O ' AREFV TANK,PIT OR SUMP INSPECTION BY DATE FINAL INSPECTION BY E / 1 ADDITIONAL COMMENTS: , N FAC# ACCOUNTING ONLY: AID! pE CODE F111 NFO AMOUNT RVAITED IEC ASH RECEIVED BY DATE SR I PGRIOT NUMBER INVOICE I 2 Pub.Health Serv.-Errviro,174 0m) i