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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 ICBmPIAu in T* iut.j APPLICATION IS 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 JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION JOB ADORESB,SOR AAPN# YJ130 D4'% L, P-15- OWNER'S A. ER'S NAME VT 7Ll,1'O l J0.N r,K,S l/ ag `• C/_ - r L{E.I�—I I Cm, K11- �1(JE�.-1 rJ ✓� LOT .17.E23 *C pFgNE_C 3L-Q AI /4q^ ADDRESS -E� [OG�Gr CaAlj- '�� L� CONTRACTOR j�'3'yL, N. V' jJ L,.*VVI tA1 y { TT16603 ADDRESS_ r'Q. 13ex 1 Q y EkkE�AfZ L�� PHONE d V -O BUR CONTRACTOR AODRESB LIC, rMONE TYPE OF 49PTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DEnTmUCTION IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 2- FEET OF BUILDING.) FERC TESTIS) I I WJW MANY INSTALLATION WILL SERVE: RESILIENCE ❑ COMMERCIAL ❑ OTHER ❑ APpIa�Van A NUMBER OF WINO UNITS: NIIMSER OF BEDROOM : NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PFPSUMP SOIL CHARACTER: WATER TABLE DEPTH_ SEPTIC TANIUOREASE TRAP ❑ TYFE/MFG CAPACITY NO. COMPARTMENTS PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION ❑ SIZE T'!PE OF PUMP SANG OIL SEPARATOR (ENCLOSED SYSTEM) _ LEACHING NNE ❑ NO. S LENGTH OF UNLS DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE FILTER BED ❑ WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE MOUNDED ❑ WIDTH LENGTH_ DEFTH DISTANCE TO NEAREST: WELLFOUNDATKON PROPERTY UNE SEEPAGE RTS ❑DEPTH SIZE_ NUMBER DISTANCE TO NEAREST: WELL COUNDATION PROPERTY UNE BUMPS ❑WROTH LENGTH__ DEPTH DISTANCE TO NEAREST; WELL _ FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑ WIOTH LENGTH__ UIEFTF DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOPDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS, AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOVANO: 'I CERTIFY THAT IN THE PERFORMANCE OFTHE WOFIK 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 CAUFORNIA.• CONTRACTOR'S MIRING OR S SU CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WOPKMAN'B COM NRATION LAWS Of CAUF9RNIA.' THE APPUCA NT MUST CALL 24 HOURS IN ADVANCE FOR AU. REQUIRED INSPECTIONS. COMPLETE DRAWINQ BELOW. C0:7 SIGNED A 0--1' Jf-7 C'+^`'^-.. TITLE:_ �--d`-4-K i -S Ce .� DATE: PLOT PLAN (DRAW TO SCALE) SCALE ' to 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. O. OIMEN$IONEU OUTLINES AND LOCATION OF ALL EMSTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON IN COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS_ THE PROPERTY OR ADJOINING PROPERTY, _.. r ..... SAN :`U�LtCHEkL7iy1!r`'!::) , Lie - In ........... VIRbi+IMFt`�b I , .... ..... c c r----ra r ... APPLICATION ACCEPTED BY TANK, PIT OR SUMP INSPECTION SY-{� �}� ADDITIONAL COMMENTS: 7 1 K 'T FOR DEPARTMENT USE ONLY FINAL 6'/so /d ACCOUNTIN.O ONLY: AID, FACA l/ ag `• C/_ PE CODE FEE INFO AMOUNT REMITTED CMECKA AS" RECEIVED BY DATE SR I PERMIT NUMBER\\ INVOIC ° ° Za O L I. M&s-f call -For-�i �I a a -F de k o @ 111W-3-5120