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wbeATION FOR LIQUID WASTE PERMI 1J►��_�� !�'�' AASIN COUNTY PUBLIC HEALTH SERV&1�AQLTIN�IIMENTAL HEAL1�iFt' RONVIIt 1'ni F.N DIVISION :1'." +PUF�.It Jtrn,?,�'iI SF.RVI �. �A0 , 304 EAST WEBER AVENUE, STOCKTON, CA -s� C' (209) 408.3420 ,,,, �-I 1,l-A, (,,N 110N•11EFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TTipikats) A LIC ATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. TH19 APPLICATION IS MADE IN COMPLIANCE WITH SAN J AOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 1 10.3 AND THE STANDARDS OF SAN JOAOUtN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNM 4f r 2!J ""' l09&b I.C•CP•S• CITY_�'�.>'f -f I •'1'JZI/" Lot SIZE OWNER'S NAME � ��Q-O,Okx e- (6S ADDRESS .5PHONE CONTRACTOR -ADDRESS LIC! PHONE SUB CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIMADDITION DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PMC TFATW 1 I HOW MANY ADdlo�tlon I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTEn OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.At LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION_ RTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION 3fi RTY LINE �T C � SUMPS / XWIDTH�LENGTH IS DEPTH /7 Z DISTANCE TO NEAREST:WELL I CV-01+FOUNDATION PERTY UNE DISPOSAL PONDS ❑WIDTH LENGT/I DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 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 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 THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE RTIFIE9 THE FOLL WINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO RKj, WOMAN'S COMPENSATION S OF CALIFORNI THE A ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. I_. Pa . SIGNED X � TITLE DATE:__ 4 PLOT PLAN(DRAW TO SCALE)SCALE 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF TILE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HVNORED FIFTY FT.ON INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS.AND WALKS. THE PROPERLY OR ADJOINING PROPERTY. h(Cook .. ...:...1-twx.ti-'(-'. .r �+-...,,D P.e• �c�s``•c a< i-..:, lM.,�.n,.iA/ �1' w1.+�. .. t z d"N G.e `� Sv.L.u.I .a I�.t.a�J• vItifFi�el Ip o�,t7#f-ti.4f. (7'tT.'f/��✓�c�L.: -�wa ».2a Su rli`. :ui[d 10t +j. p we r� �►�— :. / 1QCQ� ✓17L �� '� �i Sk �S 1 stib, t idGl - Ow,.a.r 4.0 p(ae2 `2 ,vck era pe •P Pt.� 1t / I .... :.. ;.. .. PAYMENT . RE C -WED _ UG 2 9:1997 ....... ....:.....>..... ..:. • ... .. _ _ � ��•�}... " $AN JOAOUIN COUN • i PUBLIC.H5-AL.TH SETiVIG, S `. ENVIRONMENTAL HEALTH NVISION _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: ° ! ( AREA: TANK,PIT OR SUMP INSPECTION BV DATE / / FINAL INSPECTION By ' DATE Ole ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED CHECK/ ASH RECEIVED BY DATE BA/PERMIT NUMBER INVOICE 42 . /S o2So �0• a-U d / O b`f/a8�