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PLICATION FOR LIQUID WASTE PERMIT <br /> SAirJOAQUIN COUNTY PUBLIC HEALTH SERVICES - F O L. E COPY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 88, <br /> P,O, BOX 3304 EAST WEBER AVENUE, STOCKTON, CA 95201 W <br /> (209( 4883420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TrIplicate) <br /> APPLICATION 18 HEREBY MADE TO TIRE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTAU THE MW DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11"10..3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRFSSIOn AMR (1481 �(�. 1J,J X11 /1,1�� APN US9-070-0' -c I' <br /> L� T '1FA� LOT'n S3 <br /> O✓JNER'S NAME GU,('I V\(1IAQ�I,�� ��"J � la ` III,D ADDRESS �rp 0✓T V FT 11�N �Il PH�O�N3f $3G'0,, <br /> COWRACTOR ('l, Y` •� rSf�Vl ADORE66� N f�0 LIC/ PHONE <br /> s� Z�wE FIND 3 I <br /> SUB CONTRAf,TOR ADDRESS L V o <br /> TYPE OF SEPTIC WORK: NEW INETALLATIO REPAIR/ADDITION ❑ DESTRUCTION ❑ <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING. PISIC TF/TPI III 1I1 HOW MARY �J <br /> APPIIP.SPR f_y/ P <br /> INSTALLATION WILL SERVE: RE6IDENCBsFki.�. COMMERCIAL EIOTHER�ChurL�� S✓L•L� I�Sol+oc�� <br /> NUMBER OF UNNO UNITS:_a__ NUMBER OF BELMOOMB:5 A,,) Li_ NUMBER OF EMPLOY'EEII: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANK/ORFASE TRAP ❑TYPEMFG CAPACITY NO.COMPARTMENTS <br /> PRO TREATMENT PUNT❑ DISTANCE TO NBARUT: WELL FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR IENCL06ED SYSTEMI <br /> LEACHING UNE ❑ NO.♦LENGTH OF UNES DISTANCE TO NEAREST:WELL FOUNDATION gOPERTy UNE <br /> FILTEII SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED 13 MOT" LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEEPAOf RTS ❑DEPTH 812E NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SUM" ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> 018MBAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I HEHEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE NTTN SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> 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 WHICH <br /> THIS PERMIT 16 ISSUED.1 SHALL HOT EMPLOY ANY PERSON IN SUCH A MANNER A6 TO BECOME SUBJECT TO WOIKMAN'6 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> SURCONTRACTINGSIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WOR(MAN'6 CO NSATIOON7eeLA'WS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 MOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS. COMPLETE DIUWING BELOW. <br /> SIGNED% 6LUb �� <br /> TILE L L DATE: �- , <br /> PLOT RAN(DRAW i0 SCAIEI SCALE_- T <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF MUSE SEWAGE DISPOSAL SYSTEM OR POPUSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND POFOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DNVEWA/Y`S,,AND yWAU(S. THE PROPERTY OR ADJOINING PROPERTY, <br /> r <br /> P se 3 <br /> 112iIA:.,.. <br /> Sanctuary <br /> Phase 3 <br /> tz"A AENT <br /> SundoyAWood : -' EcEoaaEn z <br /> SEP g low <br /> anwleDOn Pend { — — ...:. �.,�/ a / 1Tr° '`�+�+' <br /> x Phase 2 ( ., 4' PU&JC HEA N COUNTY <br /> 1— y a ENVIRpNM HEA SE <br /> — SIJ.L A, „/ P EMgL HFpLTAHV IC" <br /> } - L J T �1r °VISION <br /> 'yYP�pp� '-� 5°°daY _ ' 3 APN 059-070-01 <br /> y� <br /> Scale 1 Inch = 160 feet <br /> DEPAR ENT USE ONLY / cis APPLICATION ACCEPTED BY V�' t/-L/' Lam! L `-'V`"'�- DATE: l b L[ci \ AREA: 2-1 <br /> TANK,PT OR SUMP INSPECTION BY / A / DATE ! ! FINAL INSPECTION BY EE/-f" j/�LL:,Li✓ DATE / Cl l <br /> ADDITIONAL COMMENTS: Jy /�A)i/ •J J(, /'/ -7�/%/ C rI4 ._�/// !//� ./!Y/ - / i /C:Ni 1 <br /> 'ri`c---(� ,' � �-rfC(� r /�la✓I �/� sV7/r�i. �,P, ,�- Jo L_L=� , <br /> ACCOUNTNO ONLY: AIDE FACE <br /> PE CODE FEE INFO AMOUNT REMITTED CHECKEIC SH RECEIVED BY DATE SR/PERMIT NUMSEPI INVOICE F <br /> �- 5>,> 0 *cd, o ql glq O �S <br />