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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOJ(388,446 N.SAN JOAQUIN ST., STOCKTON.CA 952010388 (209)US-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE ICBIIIPIAu in T*iut.l APPLICATION IB HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE:CHAPTER 8-1110.3 AND THE STANDARDS OF SAN JOOA/QUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADORESB,SOR AAPN# 13d o"% L,rdC,l- -/4q^(L{L.I�—I I Cm, y�Lf- y.� LOT EI ZE23 *C OWNER'S NAME VT 7 A.YAV0 t J0.N � r-,OL4I ADDRESS 2-EV [OGjGr CaAlj- �y(J(�.-1 rJ✓� pFgNE_� '�� L^� y ,J�� 1663L-Q CONfRACTOR__L'Y_Q2nll N. V' VL.*VVI IV% { ADDRESS_ r'Q. 13ex 1 Q y Ekk�AfZ LCN PHONEALL-03�O BUR CONTRACTOR AODRESS UCP FMONE TYPE OF 49PRC WORK: NEW INSTALLATION❑ REPAIRIADDITION❑ D-TIRUCTRON IND SEPTIC SYSTEM PERMITTED IF PUSUC SEWER IS AVAILABLE WITHIN 2-FEET OF BUILDING.) PERC TESTIER I I WJW MANY APpIa�Kan i INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER❑ NUMBER OF WINO UNITS: NUMBER OF BEDIROOM: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PFPSUMP SOIL CHARACTER: WATER TABLE DEPTH_ SEPTIC TANK/OREASE TRAP ❑TYFE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE T'!PE OF PUMP SANG OIL SEPARATOR(ENCLOSED SYSTEM) _ LEACHING UNE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER Bm ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH_ DEFTH DISTANCE TO NEAREST:WELLFOUNDATKIN PROPERTY UNE SEEPAGE RTS ❑DEPTH SIZE_ NUMBER DISTANCE TO NEAREST:WELL ;OUNDATKIN PROPERTY UNE BUMPS ❑WROTH LENGTH__DEPTH DISTANCE TO NEAREST;WELL _FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIOTH LENGTH__UEM DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 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 FOLLOVANO:'I CERTIFY THAT IN THE PERFORMANCE OFTHE WOR(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 SIB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOFKMAN'B COM NRATION LAWS Of CAUF9RNIA.'THE APPUCA NT MUST CALL 24 HOURS IN ADVANCE FOR AU.REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. C0:7 SIGNED X OL----". Ef.'/j Y+^t. TITLE:_i�BK t"S Ce .�DATE: !/ 1 PLOT PLAN(DRAW TO SCALE)SCALE 'to 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ` 2.OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ,`-`�\J O.DIMENSIONED OUTLINES AND LOCATION OF ALL EMSTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS_ THE PROPERTY OR ADJOINING PROPERTY. ..... SAN 4 31 E7+IVIRQI$MFNTI LLT .. :... `.L ,.... n.. ..... Q .. .... . :. :.. . .. FOR DEPARTMENT USE ONLY �j sit, APPLICATION ACCEPTED BY DATE: B d ,AREA; 219 TANK,PIT OR BUMP INSPECTION By . DATE / / FINAL INSPECTIO -� ADDITIONAL COMMENTS; j 1 L,J lE.*T~ qlr tlo 24 - ACCOUNTING ONLY: AIDN FACT ��/© �� PE CODE FEE INFO AMOUNT REMmTTED CHECK.( ASH RECEIVED BY DATE SR I PERMIT NUMBER\\l/ INWIC 0 li °° Za O71 VZ L f�tlis-f cQl -For -�i�I a a-F dem @ 'W 3`(20 T