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IF APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,446 N.SAN JOAQUIN ST, STOCKTON,CA 96201.0306 (209)4883420 NO -REFUNUA6LE PERMfT EXPIRES I YEAR FROM DATEISSUEO (Complete in TrlplkvtP) AFPLJCATIO.V IS HERFBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WDRL DEECINBED.THIS APPLICATION IS MADE IN COMPLIANCE'A TH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTYPUBLICHEALTH SERVICES,EEN,IVVII�ROWE/NT�A,L HEALTH DIVISION, JOB ADDRESSIOR APN4 J iJ�� 121L�/L%s�// dA, /�7—y/�,yr cm�� OWNER'S NAME ADDRESS CONTRACTOR t ADDFEBS UGI PHONE SUB CONTRACTOR ADDRESS TYPE OF SEPTIC WORK: NEW MSTALLA710N❑ 1—ABVA mmm K Du TRUCTION❑ �`�� INO SFPFIC SYSTEM PFRMT CD I�PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUKDING.I P6C—TI..I I NON MANY AppepEan/ UI INSTALLATION WILL SERVE: RESWEHCE ji COMMERCIAL❑ OTHER❑ NLMBER OF HYING UNITS:_NUMSnt OF SEDHD0MS'--5 _NUMSER Of EMPLOYED, V I CHARACTER OF SOR TO A Of"M Of 33 FEET:—'qA 4/0 y PITMUMP BOIL CHARACTER: 1 WATER TABLE DEF7N ryW 6LTRIC iANOGREASE TRAP LJ TYP Z,. T CAPACRI' NO.COAiARTMFMB PKO TREATMENT RANT❑ DIATANCE TO NEAREST: WELL FOUNDATIO PROPERTY'UNE LIFT STATION❑ SUE TYPE Of PUMP SAND OIL SEPARATOR]ENCLOSED SYSTEM] _ LFACNNUNE r T0N _!r"�P ERIY UNENN _ FILTER FED �WIDTM IENOTN DEPfN DISTANCE TO NEAREST:WELL FOUNUATIDN PROPERTY UNE MOUNDED ❑WAUTH LENGTH_ DEPRN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SFEPAGE FRT& ❑DEPTH WE_�}E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SLIPS WIDTH LEMsTN 1f1�DEPTH DISTANCE TO NEAREST:WELL 1o_FOUNDATION .��rJPOPERRY LME4gszjff�� DISPOSAL PONDS ❑WIDTM LEN(TH DEPTH DISTANCE TO NEAREST:WELL`FOUNDATION PROPERTY UNE R HEREBY CERTIFYTHAT I HAVE PREPARED THIS APPJCATION AND THAT THE WORK WALL OF DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,ANO RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORUCENCED AGENT'S SIGNATURE CERTIFIES THE FOLLOWANG:"I CENTIP/THAT IN THE PERFORMANCE OFTNE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SMALL NOT EMPLOY ANY PERSON IN SUCH A MWALR AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OE CALIFORNIA.- CONTRACTOR'S NISNG OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWANGHI :'I CFRTWY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERwT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.'THE APPLICANT MIST CALL 34 14GU1S IN ADVANCE FOR ALL REQUIRED NNSIECTOMS. COMPLETE DRAWING BEROLO'1W/.,%q� �^' SONEDX ,% If-.f" TRI E'_ IT DATE: ��ir/ ROT PUN DRAW TO SCALFI SCALE ---le 1.NAMES OF STREETS OR ROADS NEAREST TO OB SOUNDING THE PROPERTY, 4.LOCATION OF HOUSE SEWAGE,DISPDSAL SYSTEM OR PROPOSED Z.OUTLINE OFTHE PROPERIY,WrTH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, ].DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTUWRs, S.LOCATION OF WELLS WITHIN RADIUS OFONE HUNDRED FIFTYFT.ON MCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WAIXS. E PROPERTY OR ADJOINING PROPERTY. SEA, - �✓ ,,`�g+.IC RGI. 18 a • _. . 7AA+ X55 E R�fb/J . .2 Q .410 / FOR OFPAA—M TUSEONLY APPLICATION ACCEPTED RV �` ��T-.S./S DATE: .SPLA �/�_G TANK.RT OR SUMP INSPECTION BY DATE FINAL INSPECTON BY DATE 9_ 1 2 ZI J ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDE FACT PE CODE FEE INFO AMOUNT REMITTED CHFC ASM RFLBVID SY DAT( OR I PWMT NUMS61 INVOICE l L I I ire. 34?7 4 a- ap L � St�doo�3�t3