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APPLICATION FOR LIOUIDIASTE PERMIT ~� PUBLIC HEALTH SERVICES >1YI jow'm C" "�' NMENTAL HEALTH DIVISION B�IViR011t NT� �_SA ST STOCKTON,CA 95201.0388 SpliCL" T (2091488,3420 L - ?NON--�IEFUNOABLE PEBMR EXPIRES 1 YEAR FIIGN DATE ISSUED L (Gnpbn ii Triplicibl MPLICAT/ON IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 19 MADE N COMPLIANCE WITH SAN JOAOUIN COUNTY D'VELOPMENT TIRE,CHAPTERS-1110,3 ANO THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMBION. JOS ADMSSIOR AAAI ��s / D i A b L o G r cRTY T x e- LOT a¢E S A OWNER'S NAME To ht r AM► �R/C REGRESS S P'I Md • PFIONF CONTRACTOR/ /S B NY Y SAN ADDRESS -"IJI RL✓7" Mod-K1z' uu yf9 fV F1101E SUE CONTRACTOR ADDRE98 LICA PHONE TYPE OF SEPTIC WORK: N1S INSTALLATION❑ REFAN/ADDFTON ONtTPRU.TION❑ NO SEPTIC SYSTEM PERMITTED F PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.? PSC 7871.1 I I NOW MANY ASPioslbw P INSTALLATION WILL S9WC RESIDENCE 89 COMMERCIAL❑ OTHER❑ NLMER OF UVNO UNITS! I Num OF EEDIk1OMS:�_NL%MM OF INIPL.O Ym: CHARACTER OF SOIL TOA DEPTH OF 3 FEET: G L y PT)SUMP SOIL CHARACTER: L Z4 L r WATER TABLE C*FM / A _ SEPTIC TANKIOREASE TRAP ❑TYKmf;G_ CAPACITY NO.COMPAJITUEHTS ►PLO TRFATUIRIT PUNT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LTE LFT STATION❑ SIZETYPE OF RUMP SAND OIL SEPARATOR IENCLOSCO SYSTEMI N LLACHNO UNE 0 NO,A L.ENOTH OF LINES�L' C70 A 3 DISTANCE TO NEAREST:WELL FOUNDATION do, PROPEISTY LINE J O FKTM BED ❑WROTH LENGTH —DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LBE MOUNDED ❑WIDTH LENGTH _DEPTH NOSE ANiCE TO NEAREST:VYf11 —FOVNDATDN PROPERTY LIN RE SEEPAOS PS 13DEPTH SIZE NUMBER DISTANCE TO NEAREST:WALL FOUNDATION PROPERTY LINE SLMM �WIpTHLENGTH r DEPTH DISTANCE TO NEAAEST:WELLFOUNDATION PROPERTY LINE O DISPOSAL PONDS ❑WWDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOES(WILL BE DONE IN ACCORDANCE W!TH SAN JOAQUIN COUNTY OFDIFANCES AND STATE DWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOMEOWNER OR UICENBED AGENT'S SIGNATURE CERRIFIEB THE FOLLOWNG:'I CERTIFY THAT IN THE PERFORMANCE DF TIE WONC FOR WHICH THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY ANY PEA90N N SUCH A MANNER,AS TO BECOME SUBJECT TO WOWK AAN'E COMPENSATION LAWS OF CALY-0RNLI' CONTRACTOR'S HIRING OR 6NT SVCORACTIN13 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN TAE PEFFORMANNCE OF THE WOE.POR WHICH THIS PERLUr 19 ISSUED,I SHALL EMPLOY PERSONS OUBJE'GT TO WORKMAN'S COMPENSATION 'LAV 99 OOF/CALIFFO,IMA.'THE AMUCANT MUST CALL U HOURS U ADVANCE FOR ALL RBOLUR M INSFBT10N4. COMPLETE DOWSING BELOW. SIGNED xn///:1�JLOf - TTR4: DATE: RAT MN WAIN TO SCALER SCAL. 'le 1. NAMES OF STREETS OR ROADS NEAFES'T TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE 04SMSAL SYSTEM OR PROPOSED 2.OUTU?JE OF THE PROPCRTY,WRH DIMENSIONS AND NORTH ONECTON. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIUENSIOREO OUTLINES AND LOCATION OF ALL"I9TNG AND PROPOSED STRUCTURES, E.LOCATION OF WELLS WITHIN RADIUS OF pE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS OUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PIOPERFY OR ADJOINING PROPEIRY. "t ,:.. ... ...., : .: ..w.. • ............:... : SII • ........., . .. . .. :... . . :....... ....................... ...: €..........€. .'s,.. ' ...:.... .... ............., . .: .. ... . .....:...........`...... . . 1.. I.. 1 ..... .....: ,1 ...pp�t►e-a,�n RL?�Nti LCJUNTY ..............L.........i...._;.. , .... i PU13IC iLIF i SL"F3VfG`ES t............ ._ ..• . uYJlt�{JANNENTRL HEAL7i _.. :. ' y gIOIv POR DEPARTMENT USE ONLY APPLICATION ACCEPTE'.O Sy DATE: TAMC,PT OR SUMP INSPECTION BV DATE I f FINAL INSPECTION BY DATE RI y 9 5 ADOTK)NAL COMMf NTS: �A�p ACCOI'MTINO ONLY: AID/ FAC! r— P[CODE FEE INFO AMOUNT 111MITTm C... RSCIIVED SY DATE OR I PBS•ET NLWOMM INVOICE Z I 52oov�"l�r�--