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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 85201-0388 (2OI) 488.3420 1101tREFURDAELE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED learriplits /II TripWaal APPUCATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CCINSTRUcT AND/OR INSTALL THE WORK DESCRRED. THIS APPLICATION 16 MADE IN CCIMPLIONICE VATH SA.N JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 8-1 1 10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH CiviSION, JOB ADORESVOR ARNO 30 COS% Pec.1( 174— crry LOT eIZE 1.3 HT. 0 .8 NAME.ji k IOILS G S0. IC4LS A DORM CI PC7C.*- 51trIE.,k--kb F,„ et-G 2-- 1 0S4-, CONTPLACTORailiev, e D 104 t ADDRESS P' 11.1!1 X 89-- C4. LIC• PHONE 84,3 - 0 3 CI g sue CONTRACTOR AODRESS ITS PHONE TYPE OF SEPTIC WORK: NEW INSTALLADoN 0 AvAmurzoinom 0 (NO SEPT. SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN ZOO FEET OF BUILDING./ PERC TESTNI 1 1 WJW MANY Applia•Oon DEsTmucTioN INSTALLATION WILL SERVS RISIDENcE 0 COMMERCIAL 0 OTHER 0 NumsER OF LRINO UNITS: ITUNIS161 OF ISIDROOTAS: NUMBER OF EMPLOYEE": CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH EPTIC TANIUGREASE TRAP 0 TYrE/MFG CAPACITY NO. COINIARTMENTS REG TREATMENT PLANT 0 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UfT STATION El SIZE TYPE OF PUMP SANG OIL SEPARATOR (ENCLOSED SYSTEM) LEACIEND LINE 0 NO. • LENGTH Of LINES DISTANCE TO NEAREST: WELL FoUNOATION PROPERTY USE FILTER MED 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUFLIATION PROPERTY UNE MOUNDED 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY USE SEEPAGE TITS 0 Demi Dm NUIMER DISTANCE To NEAREST: WELL FouNDATION PROPERTY LINE UMPS 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UHF DISPOSAL P01105 0 (MOTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY USE I HEFUEST CERTIFY THAT I HAVE PREPARED TWO APPUCATION AND THAT INE wow WILL SE DONE IN ACCEATKIANCE WITH RAN JOAOU1N COUNTY ORDINANCES AND STATE LAWS. AND RULES AND REGULATIONS OF THE SAN JOAEMIN COWRY. HOME OWNETI OR 1LCENEED E61.5 SIGNATURE CERTIFIES THE FOLLOYANG: I CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WWCH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AB TO BECOME SLIEuEcT TO WORKNIAJ4111 COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING ON SUIT-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY iHAT IN THE PERFORMANCE OF THE WORK foil WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WOMMANS COUENSArION LAWS OF CAURNINIA.' THE APPUCANT MUST CALL 24 NOLA{ IN ADVANCE FOR AU. REQUIRED INSPECTIONS. COMPLETE DIRALMNO BELOW. !OOHED X PLOT PLAN (DRAW TO (CALE) SCALE i. NAMES OF STREETS OR 113A1311 NEAREST TO OR SOUNDING THE PROPERTY, 2. OUTUNE OF TEE PROPERTY. WITH DOADISIoNs AND NORTH DIRECTION. 2. OIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS AM) WAI KS. TrnE: 10 4. LOCATION Of HOUSE SEWAGE DISPOSAt SYSTEM OR PROPOSED EXPANNoN OF SEWAGE DISPOSAL SYSTEMS. S. LOCATION OF WELLS IMTHIN RAMO OF ONE HUNDRED FIFTY FT. ON THE pflopERTY OR ADJOINING PROPERTY. DATE: /47A:9 1)-00 APPLICATION ACCEPTED BY 7VtL DATE: A.F.134, 219 DATE /C) ACCOUNTINO ONLY: w• AIDS FAC• dR0467,. PE con, FEE IWO AMOUNT RiasTrED , CHECKS RECOVED MY DATE SR / PERMIT NUMB. INvOIC q7.-24FEW • mlimEmmarfamium A .., ZffE4 I Man' ca/f or -q ( c'4 dek-fr) e 2/a-m2o TANK, PIT OR SUMP INSPECTION BY FOR DEPARTMENT USE ONLY