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APPLICATION FOR LIQUIQ WASTE PERMIT
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH',ERVICE:S
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> 304 EAST WEBER AVEtNUE, STOCKTON, CA 95202
<br /> (209)468-3420
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<br /> NON-REFUNDABLE PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Lj
<br /> ICompMts In Trlplieats)
<br /> rs• APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PEPIT TO CONSTRUCT ANDIOR INSTALL THE WORT(DESCRIBED. T1418 APPLICATION IS'MADE IN COMPLIANCE WITH SAN
<br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11 0.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.
<br /> JOB ADDRESSMR APNR f,`+,�J 9 f L` _`�../ C/ CITY / LOT S1ZE '
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<br /> OWNER'S NAMEJ�I/'' A, 'DR-)A�E C-Z- ,��Ll A ��JIY�--_1 ...L_ZPHONE C7 51
<br /> CONTRACTOR f--�f��fC�ST e1�AbtrRES6 TO �C�N LL• LIC/ PHONE1 �
<br /> SUS CONTRACTOR - ,S `T ADDRESS UCS PHONE
<br /> TYPE OF SEPTIC WORK: NEW tNSTAWTION REPNRIADDITION ❑ bESTRUCTTON ❑
<br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF 13UIUXN0J PtlGC TESTId f 1 HOW MANY
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<br /> INSTALLATION WILL SERVE: RESIDENCE�91 COMMERCIAL❑ OTHER ❑
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<br /> NUMBER OF UVINO UNITS' NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: f
<br /> CHARACTER OF SOIL TO A,'DEPTH OF 3 PEET- f d/T,�,^PITAIUMP SOIL CHARACTER:L.O-.461�'��Wt/ATER TABLE DEPTH
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<br /> SEDTIC TANKMRFASE TRAP D TYPEIMFG CAPACITY NO.COMPARTMENTS
<br /> PKG TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY USE
<br /> LIFT STATION 0 SIZE TYPE OF PUMP /��, BAND OIL SEPARATOR(ENCLOSED SYSTEMI r ppp�����CJJJ
<br /> LEACHING LINE NO.&LENGTH OF UNES(Z^J �'t'C/ �. —/e 41DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> FILTER BED ❑W E TH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY USE-
<br /> MOUNDED ❑WIDTH_LENGTH DEPTH [!STANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> SEEPAGE PITS ,DEPTH SIZE�G�rr NUMBER•_„'�Z-�[(STANCE TO NEAREST:WELL FOUNDATION, ,? PROPERTY CINE
<br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY USE
<br /> DISPOSAL PONDS. ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE (�•
<br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES \TVG]
<br /> AND REGULATIONS OFTHE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFLESTHE FOLLOWING:'LCERTIFYTHAT INTHE PERFORMANCE OFTHE WORK FOR WHICH
<br /> 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 HIRING OR
<br /> SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:h CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO
<br /> WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW.
<br /> SIGNED X/ Z� r TITLE:- ✓:� DATE:
<br /> PLOT PLAN(DRAW TO SCALEI SCALE,,, 'to
<br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM OR PROPOSED
<br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.
<br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON
<br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY.
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<br /> FOR DEPAPTMENT USE ONLY
<br /> APPLICATION ACCEPTED BY DATE: /or Cr 9 AREA:
<br /> !2DIT ` UMP INSPECTION BYwit -'DATE 9I ,FINAL INSPECTIONS DATE
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<br /> K)N CO NTS:
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<br /> ACCOUNTING ONLY: AID/ FACO
<br /> PE CODE FEE INF[ AMOUNT REMIITED CIGEC 1C ASH RECEIVED BY DATLz'.- SR I PERMIT NUMBER INVOICE I
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<br /> ub.Heard,Serv.-Envlro,174(3/96)
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