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APPLICATION FOR LIQUID WASTE PERMIT (jO,/ AN'JOAOUIN COUNTY PUBLIC HEALTH SERVICt- ENVIRONMENTAL HEALTH DIVISION ,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 S i 2 L (209)1488.3420 REFONOABIPEM,PIRES 1 YEAR FROM DATE ISSUED —160 55 (Complete in Triplicate) �O APPLICATION t8 HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION I8 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT �TITLE. CHAPTER 9-11 10.3 AND TIIE.4f\l(�V,D-.�ARnDS^OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/On APNI aj/ � V 0,f[A J CA CITV roe LOT RI7.E3ACre& OWNER'S NAME G DS(;1I Vf4t ADDRESS �7 4 '• -�M OY\ �!�r f, M10NE q�DpC/� _W4,1O CONTRACTOR l f eYlpry e(11•�� ✓ ADDRESS -.114 c�e� CK�h,� UCI MiONE 5119 CONTRACTOR ADOTIFAS 1JC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATI REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TE@Tld l MOW MANY INSTALLATION WILL SERVE: RERIDENCF.❑ COMMERCIAL ❑ 0IIFR NUMBER OF UVINO UNITS: NUMBER OF BEDROOM@: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: MT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MTYI__ ___ CAPACITY NO.COMPARTMFNT9 PRO TREATMENT PLANT❑ DISTANCE TO NEARFAT: WEIL FOUNDATION PROPERTY LINE UFT STATION❑ S17E TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED BYSTEMI LEACIeNO UNE ❑ NO.6 LENOT/I 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 PROPERTY LME SEEPAGE PIT$ ❑DEPTH 812E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMP$ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULE@ AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'@ SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIrYTHAT M THE PERFORMANCE OF THE WORK FOR WISCII THIS PERMIT IB ISSUED,1 SIIALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AB TO BECOME @OBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOLKMAN'8 COMPENBA N LAWS OF CALI IA.- THE APPLICANT MUST CALL 24 HOUR$IN ADVANCE FOR ALL REOUIRED INSPECTION@. COMPLETE DRAWING BELOW. SIGNEDX `2/�� „ TITLE: DATE: �J^/ v_ PLOT PLAN(DRAW TO RCALF)SCALE 'le 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF TIIE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF REWAOE DISPOSAL SYSTEM@. 3. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PSOPOSFO RTRUCTURER, S. LOCATION OF WELLS WITHIN RADIUS OF ONF HNINDRED FIFTY FT.ON INCLUDING COVERED ARFAS SUCH AS PATIOS,DRIVEWAYR,AND WALKS, THE PROPERTY OR ADJOINING PROPERTY. `- 10 _ J c Pio L ed1A Field r APR 1919 I'VOLIC HEALTH SF'wI/iL-S • C 0 PyWV WmMFNTnI ' rpl r r>iv ti . ��TMFNT USE ONLY (_}IAPPLICATION ACCEPTED BYYAV�WC' DATE: 1 AREA: TANK,MT OR BUMP INSPECTIO1BY DATE FINAL INSPECTION DATE 11 X22 �i ADDITIONAL COMMENTS: dRor /N 30 ACCOUNTING ONLY: AIOI FACT PE CODE FEE INFO AMOUNT REMITTED CHECK/ ASH RECEVEO BY DATE SA/PERMIT NUMBER INVOICE