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APPLICATION FOR LIQUID WASTE PERMIT ff o �. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ! d F ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 XMREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TripIkate) APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCItiSM). THIS APPLICATION 19 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8.11 10.3 AND THE BTANDAROB 0LfIr JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, JOB ADDREGS=APNI 11 ff / Q CITY ti-go ` LOT BUZ&a4a OWNER'S NAME I>l 59WS T ADDRESS O r C51 b 6 PHONE CONIRACTO C.CIr"T r ADDRESS • r LIC PHONE BUB CONTRACTOR p- ADDRESS LIC. PHONE TYPE OF SEPTIC WORK: NEW TNSTALLAIYON 91 REPAIPJADDITION ❑ DESTRUCTION❑ €�• ING BEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUIUANOJ III TESTIvI 11110W MANY INSTALLATION WILL SERV£: RESIDENCE❑ COMMERCIAL [7 OTHER❑ NUMBER OF LIVINO UIaTa: NUMBER O BEDROOMS: NUMaSR OF PAPLOYEES: D CHARACTER OF SOIL TO A DEPFN OF 3 FEET: /4 —APIT/SUMP SOIL CHARACTER! �_ WATER TABLE DEPTH 6 +'� SEPTIC TANI EASE TRAP ❑TYPE/MFO Aj LJC� CAPACITY_ I Qt:;,,1 NO.COMPARTMENT�Sj� k PKG TREATMENT PLANT 13 INSTANCE TO NEAREST: WELL FOU NDATro' zw � PROPERTY LINE ICK. . k LIFT STATION❑ SINE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM! ft� LVAC14NO LINE NO.A LENGTH OF UNES� [ DISTANCE TO NEAREST:WELL FOUNDATION `'" +PROPERTY LINE �D op FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I MOUNDED E,..l,/W1113TH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE Pita l!1"DEPTH ---SIZE_NUMBERINSTANCE TO NEAREST:WELL FOUNDATION �D PROPERTY UNE�BP� / BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ' DISPOSAL PONDS ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANOREOULATTONSO SANJoAOUINCOUNTY.HOME OWNER ORLICENSED AGENT'S&ONATLWCERTIFIESTHEFOLLOWING:'ICEKnFYT14AT1NTHEPERFORMANCE OFTHE WORK FORWHICH THIS PERMITIS IS 11: NOT EMPLOY ANY PERSON IN SUCH A MANNER AS to BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUSrOHTRACTINq ATURE CERTIFIES TH FOLLOWINO:'t CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WFOC14 THIS PERMIT IB ISGUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOFKMAN'S DRAPER TION LAWS OFC RN1A.' THE oftleA UST CALL 24 HOURS IN ADVANCE FOR ALL#EOWED INSPECTIONS. COMPLETE DRAWING BELOW.�(/, 9 S1GNE TITLE: DATE: I[ ` OT W TO SCALE(SCALE 'to 1. NAMES OF ST S N PERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PRIPEITTY,WITH DIMEN9tO D NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. l•�( 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. E. LOCATION OF WELL6 WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED MEAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING pROPFRTI'. _ - -. ... , I .. . -- .. .. r ' T ... trw ... �..-..+---moi.�fY► . ....F ..... .... ..... .. .. .. .. . :. .. r,}�,'�sCm 4 .:. �99a . ..... . aULfdiV Uv EALTH�>v,it?11C1 4 5-IFALTN OlV ...... .... ...... ... .-, ....., ..,.... ......,.. ... .. ., - Y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE:jo� A TANI&OR BUMP INSPECTIOI4 BY DATE 2,f 1�, FINAL INSPECTION B ADDITIONAL COMMENTS: ' J CACI ACCOUNTINO ONLY: AID/ FAC. LL PE CODE 15"--INR' AMOUNT HIM ITED C1 H 11ECIII MY DATE on IP9WNT NURSER INVOICE. 7cr, Pub.Health Serv.-Enviro.174(3/96) . J }