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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,p,BOX 380,446 N.SAN JOAQUIN ST.,STOCKTON,CA 95201 03BO (209)4683420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUEQ t,HiP4a in Thpli"t) APPLICATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO+OR INOTA THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WfIH BAH JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARD3 OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSAIR APNI_ J a )I\ \V CRY ('.'�.t ( 1 {,,- ^7 Fy h f� yam, /� {LOT 61X �,s OWNER'S NAME t YC f1111 i;�5 1 J l Fl.T� ADORE88=L ` +�/ S-i)(r TF•fy `1 1 %:L ip. 1'•</S.3 PHONE�y�-1�T y_-11 CONTRACTOR ADDRESS LICI MogE SUB CONTRACTOR /IDDRE9e UC# FP10NE TYPE OF SEPTIC WORK: NEW INSTALIATN)N wArmaiTION❑ DESTRUCTION❑ NO SEPTIC SYSTEM P mrrrED IF PUBLIC SEWER IS AV CABLE WITHIN 200 FEET OF BUILDING.) PFRC TESTt�)I I HOW MANY A1Pdlanlbn I� INSTALLATION WILL TONE: P/E310iNC£Ed COMMERCIAL❑ OTHER[IkUMm OF LIVING UNITE: / NUMBER OF BEDROdUS; NLMM OF 111"Laym: F CHARACTER OF SOIL,TO A DEPTH OF]FEST:_C1 A V PITISUMP SOIL CryMAC7ER; WATER TABLE OEPI`Fl SEPTIC TANIIJOREASE TRAP ❑TYPLBAFG T CAPACITY L�GAs� ND.COMPARTMENTi PKO TREATMENT RANT CI DISTANCE TO NEAREST: WELL FOUNDATION ,`1 EH PROPEpTy IJNEI.0 f LIFT STAnON❑ WE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSEO SYSTEM) _ +�LEACHING UNE NOF LINED L.�,.GS X 5S A DISTANCE TO NEAREST:WELL'/A`_PoUNOATKIN esEC'I PROPERTY—E,S J FILTER NEO ❑WITTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY UNF MOUNDED �❑miyrH LENGTH_ DEPTH DISTANCE TO NEAREST:WELL FOIiNMATION PROPERTY LINE IQ SEFDAGE MT. DF'1 )5 f / NUMBER 3_ DIST 2-.. SILL� ANCE TO NEAREST:WELL FJIINDATION PROPERTY IINE!�'D _ . SUMPS LJ'WIDTH, LENGTH__DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONot ❑WIDTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 1 HERFBY CERTIFY I HAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE IANfS.AND RULES __/•1 ANOPf.GVV'fION£:G;THE SA4-IOAUUINCUUNTY.MOMFOYNIEROp LICENSED AOENT'S¢GNATVRE CERTIFIES FOLLOWNO:•ICERTIFYTHATINTIRPERFORMANCEWTHEWOry(POq WHICFI C•�^�THi6 PFRM17+S i'ir.:£'!1� RHAJ-Ii01'FMPLOY ANY PERSON N SUCH A MANNER AS TO SFCOME SUBJECT Tn WORKMAN'J COMPENSATION LAWS OF CAUFOMIA_' CONTRACTOR'S No RD OR CIIRt:0NTRACf LNG S';:NATURF CERTIFIES THE F'OLLOWINO:'I CERTIFY T1!AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY TRACTOR SUBJECT TO \"O RI:MAF-":;:UM•'F+13A7'�CN I.AWA DF CAUFORNIA.'THE AP►UCANT MUST CALL 2a HOURS IN ADVANCE FOR ALL:AEDISRED INLPECTTONS. COMPLETE DRAWING BELOW, 1 SK3NE0 X TRLE: 11LOV e-� .DATEa PLOT RAN)DRAW TO SCALF,)SCALE '.NAMC50-'il FILETS OF ROADS NEAREST TO OR BOUNDING THE WgPERry. lab.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE Of TIRE PROPERTY,Wll H DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISMBAL SYSTEMS. :1.LfIML/NCP.1,-?(+.:•;IN59 ANO LCC.ATION OF All FXISTINO AND PROPOSED STRUCTIIIV.6. S.LOCATION OF WELLS WITHN AADIUB OF ONE HUNDRED fIFTy FT.ON INCUIDIh41 AR l CO d'?RP; E . J AS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY .. O Nc��jIlbN� _u — _ _ Pcr1 ;N I Iva z r p tq..... .I... .....tn. FEB 3 _ :.. SAN JQAE)i.!E'J C _. StP!-y5� PJ9i.IC I1u.A;.TT7}-. - cl 4 EiVVIRONhiENTAI tiE°r:: r•. _ FOR DEPARTMENT use ONLY AW'LICArm ACCEPTED HY- DATE: .A; �7 L TANK,AT OR SUMP INSPE::I ION'VY OKIE f fNµ mBPECTIUN BY I L DATE_'`Ow/O $ ADDITIONAL COMMENTS: II�AC FACE C'OU�NTIN�.ONLY: AIDA m CODE FEE.To AMOUNT REMTTED NEC /CASH gECOVm Ny I GATE SR 1—IT NUMBER