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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388, 445 Al.SAN JOAQUIN ST,STOCKTON.CA 95201-0388 (2091 4883420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATS 148VED (CaMpbTA in TFsliatal APPLICATION 16 HERESY MADE TO THE SAN JOADLMN COUNTY FOR A PERMIT TO CONSTRUCT ANNDIOR%STALL THE WORK DESCRIBED. THIS APPLICATION 16 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY OEVELOPMENT TRTL/E,CHAPTER 9.1'11`0,3 AND THE STANDARD6 OF SAN JOAQUIN COUNTY PUBLIC HEALTH UMVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADWRES6DR APIdf', g/ �,,5 �i0.4-4"b b f.� r� �/ C(iY J/C3�/.''%/'1�iJ _LOT SIZE OWNER'S NAME^� tp L /ilA I ADDPE68 Cy �(9 �'�rr 5A 2�5,4,if C!IP `�� NE S�/S� CONTRACTOR?F�/ e-n AJ S�f ADDRESS_. 'j/7C..Q AM1�O j•�c;!7 f UC' —ME SUB CONTRACTOR A r2� az-1-,4,F-1-,4,F/� ADDRESS !,�-'t' ;/7e) .4,+E/ZjQo' UCi �p FHONE_3�5 , TYP£OF SEPTIC WORK: NEW INSTALJ.AT0N REPAWADDITION ❑ DEATRUCRON 0 INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITH W 200 FEET OF BUILDING.) PING TESTLU1 1)NOW MANY APPIIw Son/ INSTALLATION WILL SONE: RESIDENCE W COMMERCIAL❑ OTHER❑ NgAMi3k OF LMNO UMTa:_ / MAnM OF BEDROOM{: �S MUSS 1 OF FIMPLDYEES: fes_ CHARACTER OF SOIL TO A DEPTH OF 0 FEET:_4D a,,}T��----VPIT SSUMMP SOIL CHARACTER:''' �WATER TABU DEPTH Cl SEPTIC TANKDf•� REASE TRAP ❑TYPERAFG_ ,,�L, _CAPACITY NO.COMPARTMENTS o2I PKO TREATMENT PLANT❑ INSTANCE TO NENWT: WELL /f� i P/ FOUNDATION C7 r T PROPEPTY UNE /dl— -7— UFT TUFT STATION❑gqSIZE TYPE OF PiEMP SANG OIL SEPARATOR(ENCLOSED SYSTEM) F1. 2- pLEACHINGU N0 NE ID N0.ak LENGTH OF LINES DISTANCE TO NEAREST:WELL PROPERTY'FWfOATKIN _PPERTY LINE ploy�f FILTER BED ❑WIDTH LENGTH' DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE- MOUNDED ❑WIDTH LENGTH__DEPTHDISTANCE TO NEAREST:WELL, FOUNDATION PRDIERTY LINE aEFPALPE PITS 0 DEPTH SIZE _NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE V SLMPS ❑WIOTIN LENGTH OEPTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE OIBPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LAW S I HEREBY CEHTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TH£WORK LOLL BE DONE W ACCORDANCE WnH SAW JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ]' AND REGULATIONS OF THE SAN JOAOULN COUNTY.HOME OWNER OR LICDISELO AGENT'S SIGNATURE CERTIFIES THE FOI.LOWINO:'I CFFTIFY THAT IN THE PERFORMANCE OFTHE WORK FORWNNCH THIS PERMKT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON W SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN'HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA:THE APPLICANT MUST CALL 26 HOURS IN ADVANCE FOR ALL RISOU tED INGPECR0N6. COMPLETE DFIAII.BELOW. SIGNED X TITLL; DATE: PLOT PAN(DRAW TO SCALE)SCALE 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, Moi. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY.WITH DIMIENSIONB AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADAIS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR AOJOFMPK.PROPERTY. I ... .. Y....... .. itZ 9.0 PA9iRElafiT 1 1° �+ :. . . .... 3L1y c �IUti ENU1Fi Jrrr�1'�ilTu1 kTYI111�t� a- rte,fi; : ..............-..- ...... — _ .. ..i I. FOR DmAATh%AT USE ONLY APPLICATION ACCEPTEG BY pp7E: Lk— —;-Z f L TAW,PR CA SUMP INSPECTION BY GATE 1 1 FINAL INSPECTION BY 1 DATE ADDITIONAL COMMENTS: 1 I ACCOUNTIINO ..IT; Alp/ FACE ODE FEE INFO A 04NI R9.6TTED K ACASH RECEIVED SY DATE !►YVAT NWBEI IMVOICK•