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APPLICATION FOR LIQUID WASTE PERMIT L SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES Y" ENVIRONMENTAL HEALTH DIVISION RO.BOX 388,304 EAST WYESER AVENUE,STOCKTON,CA MMI388 (209)4683420 1110R-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comphts In Trlpiau) ., APPLICATION NE HEREBY MADE TO THE SAN JOAOLMI COUNTY FOR A PERMIT TO CONSTRUCT ANONR INSTALL THE WORK DESCRIBED. THIS APPLICATION 10 MADE IN COMPLIANCE WTIH SAN JOAOUN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND TTHHEE STANDARDS OF SAN JOA/OIXIl COUNTY PUBLIC HEALTH BIER,EN MONMENTAL HEALTH DIVISION. JOB ADOREBSIOR APNf /LJ�� J�+1 /C�..V 1 J �. .,C/rtY/) /7/,�/J LOT OWNER'SNAME !�./�/ ADDRESS ]�[/f U f4fJCJ 7 IiC/J PRONE (��(J S� CONTRACTOR ADDRESS LICE 7 PLiONE SUB CONTRACTOR ��J L.(1//1.()!1 ADDRESS_[ TYPE OF SEPTIC WORT(: NSW INSTALLATION❑ REPIVUADOITION❑ DarRIICTON❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILOO10.7 PSR:TESTbI 1 I IOW MANY AppOaWen INSTALLATION WILL SEINE RESIDENCE COMMERCIAL❑ OTHER❑ MIMBIM OF WING UNITS:_NUMBER O SIOOMS: NUVSM OF EMPLO CHARACTER OF SOX TO A DEPTH OF�33I FEET: T* SUMP X CHARACTER:WATER TABLE DEPTN_ SEPTIC TANKIOREASi TRAP iJ TYPE/MFG CAPACITY NO.COMPARTMENTS ` PKG TREATMENT PLANT❑ dfi1UICF TO NIiMEBT: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SRF TYPE OF P LIMP / SAND OX SEPARATOR(ENCLOSED SYSTEM? LEACHING LINE R NO.S LENGTH OF UNEB :S `77/�9 I rl DISTA14CE TO NEAREST:WELL,&✓CO... PROPERTY LfNE M61 0 FILTER IM ❑WIDTH LENGTH DEPTH DISTANCE TO NEAW8T:WELL FOVNDAT)ON PROPERTY UNE `` MOUNDED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE_ SEEPAGE RTS ;tOEPTHZE2 SUE N%M"EItDISTANCE TO NEAREST:WELL-1:22�FOUNOAT10N15::2 �PROPERTY LINE_ SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE C DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE H 1 HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK KALI,BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE*AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING!'I CERTIFY THAT MTEE PERFORMANCE OF THE WORK FOR WHM:H THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNW' CONTRACTOR'S HIRING Oft SVS-CGNTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 191a9UED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.' THE APMICANT MUIXT CALL 24 HOW IN ADVANCE FOR ALL REOUIRFA INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: DATE: PLOT PLAN(DRAW TO SCALE(SCALE "to {�.O 1.NAME 9 OF STREETS OR ROAD*NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIAECTOH, EXPANSION OF SEWAGE DISPGBAL SYSTEMS. L1 3. LOCATION NG ENSIONED OUTLINES AND LOCATN OF AEXISTING AMO PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN RADIUS OF ONE IRIRN RED FIFTY FT.ON r IUNCLUDING COVERED AREAE OUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY, ?--�(�'OP L� . ( A . �-a .... ..... 0 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY OATS: REO: 2/ Ll TANK,PIT OR SUMP INSPECTION SY GATE I I FINAL(NSP ON BY DATE O ! /7 ilf AOORTIONAL COMMENTS: ACCOUNTING ONLY: AID. FACT PE CODE —I— AMOUNT RENOTTFD CHECKOOCASH RECEIVED BY DATE SR I PCRwT NUMBER RNOME f Z t I PL�L `0 SRO b rt k 6