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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O, BOX 988, 344 EAST WEBER AVENUE, STOCKTON, CA 9524188 I209t 468•3420 NON•REFUNDADLE PERMIT EXPIRES I YEAR FROM DATE ISSUED FILE COPY APPLICATION 18 HEREBY MAGE TOT THE,C JOAQUIN COUNTY FOR A PERMIT T6 CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 ANO T IE STANDARDS OF BAN JOAQUIN COUNTY PUDLIC HEALTH SERcVICES,ENVIRONMENTAL HEALTH DIVISION. JORADbRE88lORAPNO 4 E• li ` ell CITY OWNER'S NAME !!5 f T LOT ,,/( ADDRESS - '/!' y -PHONE t)/,4 - CONTRACTOR �i` 0IZR)-V S I"'j}`�.•C� ADDRESS I t� CGL(yi Ci� "{' ZC J PHONE 3 -� -- �,_.., _ql BUD COIJTAACTOR ADDRESS LIC# PRIONS TYPE OF SEPNC WORK: NEW INSTALLATION REAADVADDiTION D OUTRUCTfON❑ MO SEPIIC SYSTEM PERMH"TED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET Of SUItDIF1q.► - PMC TESTI+I f 1 HOW MANY Apoleatlen s INSTALLATION WILL SERVE: RESIDENCE 0 COMMERCIAL OTHER © I HUMBER OF UVINO UNITS: NUMAEt OF BEDROOMrS:__ NUMBER OF EMPLOYEES__�7A,'`�J CH A TER OF SdIL TO A DEPTH 6F FEET iP1�- PITjB//UMP BOIL CHARACTER �/�td- WATER TABLE DEPTH C�FJ r S PITC ANKIOREASE TRAP ❑TYPEPAP �'S1-Q CAPACITY l—'T�"'- NO_COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION- / PROPERTY LINE` LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYBTEMI c/ f LEACHING UNE � NO.L>,LENGTH OF LINES. -Z,•, /i`Jtyy, DISTANCE TO NEAREST;WELL �Q ��f FOUNDATION��PROPERTY LINE /O FILTER RED ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST;VVELL FQUNDATION PROPERTY LINE, MOUNDED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION ^-7 PROPERTY LINE SEWAGE PITS DEPTH r�� gI2E-9 /f �NUMBER j_DISTANCE TO NEAREST-WELL[ �•f- FOUNDATiQN /Ly / PROPERTY LINEC-- SUMPS ❑WIOTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WiDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION . PROPERTY LINE O I HEnEDY CERTIFY THAT I HAVE,MREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES t� AND REGULATIONS OF THE SAN JOAQUIN COUNTY,HOME OWNER ORLICENSED AGENT•BSIONATURECERTIFIED THE FOLLOWING-'fC[RTIFVT"ATINTHE PERIORMANCEDFTHEWORKFORNl4BCH .SI_ THIS PERMIT 181SSUEq,1 SHALL NOT EMPLOY ANY PERSON 1 SACH A MANNER AD TO BECOME SUDJECT TO WORKMAN'S COMPENSATION LAWS DF CALIFORNIA,' CONTRACTOR'S HIRING OR SUR-CONT CT Oslo E CE THE fOLLOWIN3 ' "'TIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT Is ISSUED,t SHALL EMPLOY PERSONS SUBJECT i0 WOLRKMA 'S CO PE to OF LIFORNIA.' T A CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOWRETI INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: DATE; R`r PLOT PLAN(DRAW TO SCALEI SCALE 'to 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. Z. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH MgECMM, _ 4• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED 1 9, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PRO SED UCT REQ EXPANSION OF SEWAOt DISPOSAL SYOTEM8. INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS ANL7 rC87 S. N HUNDRED FIFTY FT-ON CATION OF WELLS VN'THN RADIUS OF E HU 40 PI 7— THE PROPERTY OR ADJOINING PROPERry, o .. ... - .. .' JUL :7199�3 I SAN.DAOUIN T I I _._,.,:. ..... _.. .....,PUBUC.REAli:Id CJ r FOR DEPARTMENT USE ONLY, APPLICATION ACCEPTED BY OATS: / - AREA;—+� TANK,PIT OR BUMP INSPECTION BY - DATE I 1 FINAL INSPECTION BY I DATE n 7 ! ! At1DIT1tlNAL COMMENTS: 71 ACCOUNTING ONLY: Alpi FAC# PE CODE FEE INTO AMOUNT REMITTED NEC !CASH RECEIVED BY DATE SR!PERMIT NIANBER _ ' f � ' INVOKE/