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10 APPLICATION FOR LIQUID WASTE PERM11 SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 888, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 / ON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED S 7V-v 5A (e`1 (Complete in Triplicate) f APP)CATION 18 HERE- ADE TO THE BAN JOAQUIN COV TY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAG IN COUNTY DEVELOPMENT QTITLE,CHAPTER •9-11.1 .3 AND THE STANDARDS OF SAN J AOUIN COUNTY PUBLIC H ERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN, LJ �•'�( t U �"' I ` "� sy G ( .L)♦ CIO tJ t l"r r LOT 81ZE ^G' OWNER'S NAME O C,f r-f "_,r 1 �g-r O .1 ADDRESS ] r p O�.A SYS\ y Tp.l YS ZI S PHONE Z.O �" 1��.C. (3x6:�V%oa of - (� o.J ADDRESS )PI-4 i"A AS_11 5 LICA' PHONE 7 SUBCONTRACTOR �.C, �&15r� LIC, PHONE TYPE OF SEPTIC WORK: REPANUADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PEPMETTED IF PUBLIC,SKEW/ER IS AVAILABLE WITHIN 200 FEET �,O OF SU'ILLDING.) 1 ' PERC TEST()ISI NOW W�MANY INSTALLATION WILL SERVE: RESIDENCE L!7 COMMERCIAL ❑ OTHER L.b r(�(� �A��\ M A Appllwtlon I NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: 1 CHARACTER OF SOIL TO A DEPTH OF 3 FEET; �/t C . PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH /ZO i SEPTIC TANK/GREASE TRAP ❑TYPE/MFO_ t�!j Z/4, CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE . LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.B LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER D19TANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE M SUPS C1MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WTTH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,i SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S/COMPENSATION LAWS OF`CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. v- SIGNED%_ Ln 1 ` r )N 4^l p 1y �/ \ TITLE:_ IC.,c, . DATE:S 2-- / C16 !I { PLOT PLAN(DRAW TO SCALE)SCALE / "to 300 1. NAMES OF STREET-OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 2. OUTLINE OF T14E PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE EWA SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, EXPANSION F SEWAGE DISPOSAL S OF O B. S. LOCATION T WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY, v y 2 D,: ..... . .. .... . . .. .: ... ._. .. __........................ ......:.. .. .. . . .. ..:. ..:.. . .. .. u .. .:.. .... . .. "`VG�� f� �wy/ c rit, 7 ! 67 . ... S , titin b•/, S FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: - AREA: _ TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY �v-, G c-y �j DATE O ADDITIONAL COMMENTB�f/t�/L' �: ,�7 //;/J �0/�.1�i✓// le z �.�l I/ y'CJS �y,�ja✓ /� '3�, //2�e 3 ��/�/�Cnr ll 30 ACCOUNTING ONLY: AID/ FAC# PE CODE FEE INFO AMOUNT REMITTED CHECK/CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE, Z Z Z 7