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PAYMENT PPLICATION FOR LIQUID WASTE PERMIT RECEIVED SANA.-JAOUIN COUNTY PUBLIC HEALTH SE CES SEP 1 9 2000 ENVIRONMENTAL HEALTH DIVISION I 304 EAAST WEBER AVENUE, STOCKTON, CA 95ic - SAN JOAQUIN COUNTY (209)468-3420 PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION AON•REFUROABLF PERMIT EXPIRES DEAR FROM DATE-ISSUED Com ! PNt*In Tr1sllTeatE1 APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOA]R INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT - -� TITLE,CHAPTER 8_.11 10.3 AND THE STANDARDS OF. AN JOAQUIN COUNTY PUBLIC HEALT SERVIC S. NVI NMENTAL HEALTH DVSION. JOB ADDRESSIOR APNI17,TDO 0, Cac k, � �e, jz-t> TC -c LOT SIZE 4 OWNER'S NAME ADDRESS PHONE CONTRACTOR �L� `� - ` ADDRESS LK:S PHONE SUBCONTRACTOR R —110 dJ ADDRESS LICK PHONE TYPE OF SEPTIC WORK: NEW INiTALLATION� RTpAtMADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 ANCAILABLE WITHIN 201)FEET OF BUILDING.) PEO TESTIm11 I NOW MANY Appl mdm 7 ' INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL fOTHER❑ NUMBR3t OF WINO UMTS: NUMBER OF BEDROOMS,__ CD NUMBBi OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET:/ f d{-F[c1 PTISUMP SOIL CHARACTER: WATER TAB (� 7LE DEPTH ` ++ naj4— SEPTIC TANOU EASE TRAP ❑TYPE/MFG w C I/C}YC— CAPACITY �p 00 d O.COMPARTME S Z, y PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOU D TCIO� P AERTY LINE � UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE W NO.&LENGTH Drum,_,.l 0 r e //h CS DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER NED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ETWIDTHJ LENGTH / a Dv"1.12 _•DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PT* ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE '. SUMPS C]WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISMSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE CONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FORWHICH THIS PERMIT 18 tBBUEO,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S COMPE"BAtION LAWS OF CALIFORNIA.* CONTRACTOR'S HIRING OR SUB•CONTRACTI TURIE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TMR PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOlKMAN'8 MPENSAT N LAWS OF CALIFORNIA,' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOIARED INSPECTION*. COMPLETE DRAWING BELOW. SIGNED% TITLE: c DATE: J�7 q / /~ c:-'o PLOT PAN(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 BYBTEMS. :3. DIMENSIONED OUTLINES AND LOCATION OF ALL EX3STING AND PROPOSED STRUCTUREG. 6. 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. .. ..- ,h... _ - t . u - _ .. ... .. .......1 .. .. . :JL . .... ... .: - . ... .. . :..... ...... ., . r �cc .. .. .. .. ......... . ........ .................:..... ...r... .... _ ........... . �;: 1.ON ACCEPTED BYFOR DEPARTMENT USE ONLY DATE: 99 f}� AREA: APPLICATIE/. ftLif/du�-� / +� TANK,PIT OR SUMP INSPECTION 13YL DATE I 1 FINAL INSPECTION BY DATE�� ADDITIONAL COMMENTS:.�' e vew! r /�S✓`�✓� // -77 Ac VHnmc ONLY: AID/ FACS i R pE CODE FEE INFO AMOUNT REMITTED Cl1EC 1C ASH RECEIVED BY DATE OR I P9VMT NUMBER INVOICE S le-[(v z c� z s> -- z. 9' 1 Pup,Health Sem.-Erlviro.174{3196} f i