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APPLICATION FOR LIQUID WA PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O.BOX 988,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 '9 3—ADO (209(488.3420 LL_ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J U IGmpiete in Triplketel APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110.3 AND THE STANDARDS 'F SVA()N//J,pAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOA AAPPNNI [/�J �/!. ��1 ( -I ('t[L�,Ii- (_/'L CITY /Rill �� LOT SIZEA&!�— OWNER'S NAME 1]�!V CG-i ADDRESS PHONE CONTRACTOR ��-`��_Tj�O-&E'er-5 ADDRESS c't / �'p UCl PHONE (//e SUBCONTRACTOR-�J�J`(}�L(-,:� ADDRES� � � (.L+�C-:��(��j,��y.� LACI(Wy?1—PHONE TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIRIAODITION❑ DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN ZDO FEET OF BUILDING.) PMC TESTW( I HOW MANY A,Pl—d n e INSTALLATION WILL SERVE: RESIDENCE--t MMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITS: / NUMBER OF iEDROOMe. NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: 2L' /'oryPRISUMP SOIL CHARACTER: WATER TABLE DEPTH J SEPTIC TANK/OREASE TRAP ❑TYPEJMFG CAPACITY /�C CJCJ NO.COMPARTMENTS Gam. PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE Qi NO.i LENGTH OF LINES ASO 2 DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTHp� LENGTH_DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PTB DEPTH ICT;— SIZE_NUMBERDISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I 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 L10ENOED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERJISSUULL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING ORBUB{ONRE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORC FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAOF LIFORNI THE APPUCAN UST CALL 2t HOURS IN ADVANCE FOR ALL RECURED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED% / TITLE: DATE: � Z� e,�.! PLOT PUN(DRAW TO SCALE)SCALE_ t 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. 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 AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. `t'✓. �t I1,�1 J G SP vC t _ tel l _ d t �lN.�1 SAN JOAMN COUNTY-PUBLIC HEALTH SERVICES 9 I I ENVIRONMENTAL H.EALTWDIVISION ;,AN JW SPECIAL PES MIT pu FOR DEPARTMENT USE ONLY 7 `'j APPLICATION ACCEPTED BY DATE: r , I AREA: 1 TANK,PT OR SUMP INSPE I B DATE I I FINAL INSPECTION BY DATE vQ21"210/ ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDS FACN PE CODE FEE INFO AMOUNT REMITTED CHECK/I ABH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE Rl //5- /80 59 VZ3 a 1