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APPLICATION FOR LIQUID WASTE PERMIT D 0/�Z P SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES 3 ENVIRONMENTAL HEALTH DIVISION P.O.BOX 988,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 1209)4883420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED MempIRLE in TRgllaatEl i APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIUR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE RI COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR'APPJN,/� OWNER'S NAMEp�� P�-/Y�C2 i✓� ADDRESS Q PLICNE -z CONTRACTOR I( CONTRACTOR /W 1 Kms[ ADORES6 LIC/ PHONE SUBCONTRACTOR ADDRESS UCF PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIIVADDITION ❑ DESTRUCTION❑ (O SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 2W FEET OF BUILDING.) PERC TESTNI I I NOW MANY I APpSo.lbn F I INLTALLATION WILL SFRVE: RESIOFNCE�COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITS: l NUM61 OF■ED1100MS:4_NU .OF Be1ROYEFJ: ,> I CHARACTER Of SOIL TO A DEPTH OF 3 FEET: PTTMUAIPK CHARAIV�CTER:� . WATER TABLE DEPTH S v SEPTIC TANK/ORFASE TRAP 'RTVPE(MFp CAPACITY NO.COMPARTMENT { ' 1 I PKO TREATMENT PLANT 11 DISTANCE TO NEAREST: WELL ►`"l�_ FOUNDATION _ PROPERTY LINE , LIFT STATION❑..SIZE � TYPE OF PUMP [� 'BAND OIL SEPARATOR(ENCLOSED SYSTEM) / G/�/ LEACHING LINE IkT NO.B LENGTH OF LINER 4 x J DISTANCE TO NEATEST:WEIL�II�FOUNDATION PROPERTY UNE 0 FILTER RFD ❑WIDTH LENGTH DEPTH DISTANCE TO NEAJEST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS y❑DEPTH SIZE_NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE RUMPS �'I OS VADTHLENGTH_DEPTH1DISTANCE TO NEAREST:WELL FOUNDATION_PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERLY UNE (1 I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH RAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES v AND REGULATIONS OFTHE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THEWOW FORWHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUrORNIA.' CONTRACTOR'S MRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WM1RCH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MOST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW- SIGNED X_ /L�(/iyv�� TITLE: llL_.AJ Y"C/ , DATE:11—d-2-7. (`L� r ROT PAN(DRAW TO SCALE)SCALE 'In 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ` 3. NMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON VU INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. .... ...... 777 .... _.. ......., ww i�c a sEYp�.IJ. ........ �d pr(�eIa YR t v1 wF...... .... OCT-21-1996 . s .... .. sA i"Ji Alv�Un 15 Pug IC'piEFLTR�S c.I�P1fI`77iV �i+}�" i to I II ....:... FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY DATE: /O AREA:/ TANK,RT OR SUMP INSPECTION BY DATE / / FINK INSPECTION BY DATE ADDITIONAL COMMENTS: F Z][ Kl XAQ_ wY0�L 6 `P1A 'T ACCOUNTINO ONLY: AIDE FACFACI FE CODE FEE INFO AMOUNT REMITTED CHECK/ ASH RECEIVED BY DATE BR I POWAIT NLIIW9R INVOICE• 0 2,5- oaa800