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APPLICATION FOR LI(IUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICtS ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 X88 {209} 488.3420 NWREFUNGABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED FILE 0 P Y (Complete In Triplicate) i APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNN (A . CITY LOT 812E n ILJ r f— `. /r -tb I OWNER'S NAME I ADDRESS ll J� - pHply� CONTRACTOR ADDRESS CN 'Y PHONE SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAJR/ADUiTiON ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TE6T41 I 1 HOW MANY Avlwlaetbn e INSTALLATION WILL SERVE: RESIDENCE� COMMERCIAL ❑ OTHER ❑ - NUMBER OF IIVINO UNITS: 1 NUMBER OF BEDROOM$:._ NUMIISR OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANIUORFASE TRAP ❑TYPE/MFO��°' CAPACTTY m NO.COMPARTMENTS_ PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL_I�� FOUNDATION [_.... PROPERTY LINE LIFT STATION© SIZE TYPE OF U P SAND OIL SEPARATOR(ENCLOSED SYSTEM) /moi f LEACHIN.O MINE $I NO.6 LENGTH OF LINES ! DISTANCE TO NEAREST:WELD FOUNDATION / PROPERTY LINE_ I CJ FILTFR.6ED,;� ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ' ❑WIDTH LENGTH_DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIKE�� p[1 8EEPAOE PITS of 03 DEPTH 812ETh l NUMBER_DISTANCE TO NEAREST:WELL O@ FOUNDATION PROPERTY LINE_! 0'7 1 :UMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE Y DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY ZINE 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 L} ` AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORUCENSEDAGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'ICERTIFYTHATINTHE PERFORMANCE OFTHEWORKFORWHICH� 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 SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN' O PENSATION WS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. j V. SIGNED X TITLE: - _ DATE: 1, 'L PLOT PLAN)DRAW TO SCALE!SCALE 'to 1, NAMES OF STRFET8 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, '` 4. LOCATION OF HOUSE SEWAGE DISPOSAL SY8TEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. N EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING 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, IN .. -. .. - ..,. ..,. i ...;,.. t...�. - f ,. . t� ........ . J . c� IW""N� s RE. . . UL 6 AN, i�AAU-HUIN SE8 {rte -� dVlpRt?IN ktViA'kTEiL27(Vi:'- )ao.r f - .. ,_ FOR DEPARTMENT USE ONLY /y T; APPLICATION ACCEPTED BY DATE- p�A;�� TANK,PIT OR SUMP INSPECTION BY BATE ! / FINAL INSPECTION BY_ DATE k ADDITIONAL COMMENTS: A'CCOUNTINO ONLY: AID/ FACN - w .. .Q. PE CODE FEE INFO OUNT REMITTED CHECKN ASH RECEIVED BY DATE SR!PFAMIT NUMBER INVOICE/