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IFPLICATI0N FOR LIQUID WASTE PERMIT /,'ON �q9 SAI,,.�OAQUIN COUNTY PUBLIC HEALTH SE. ICES 1 ENVIRONMENTAL HEALTH DNISION 1 � ' 304 EAST WEBER AVENUE, STOCKTON, CA 95202 20 (209)AM-3420 m 3 NOM REF NDARLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complfts In Tripikatsl 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 BAN JOAOUIN COUNTY DEVELOPMENT TT CH E' 9-1110.3 AND T STANbAR6 OF AN JOAQUIN COUNTY PUBLIC HEALTH SERVVICEB,ENVI NMENTAL HEALTH DIVISION. crrv_ �SCCJ !�I t LOT SIZE og JOB ADDRESS/OR API/ PHONE 7 OWNER'S NAME / I' ADDRESS rr fr �P/ •� ADORE88 or LK;# PHONE�,� CONTRACTOR - UCI PHONE SUBCONTRACTOR AbDIiE88 TYPE OF SEPTIC WORK: NEW INSTALLATION: REPAIR1A01'JITTON ❑ DESTRUCTION ❑ ,NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AV LABLE WITHIN 200 FEET OF BUILDING.) PER TEST(m)[ 1 HOW MANY APpYostlen/ INSTALLATION WILL SERVE-' RESIDENCE COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITS: NUMBER OF f MS-- --- NUMBER OF EMPLOYEES: D CHARACTER OF SOIL TOA HOF a FEET: pTISUMP SOIL CHARACTER: WATER TAB PT SEPTIC TANIUa1EASE TMP ❑TYPElMFG L/r CAPACITY CO PKG TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION U' LIFT STATION❑ SIZE �.TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) ' / LEACHING UNE A—HO.a LENGTH OF LINES �� f�/ _ :bISTANCE TO NEAREST:1MELL, - FOUNDATION PROPERTY UNEP — FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATgN PROPER'T'Y UNE MOUNDED (3 WIDTH_LENSTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ID DEPTH SIZE NUMBER��INSTANCE TO NEAREST:WELL FOUNDATION��PROPERTY LINE SUMPa ©WB)T1i LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE INSPOSAL PONDS ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WTH BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS Of THE GAN JOAOUIN COUNTY-HOME OWNERORL)CENSEb AOENT'8 e1GNATURE CERTIFIES THE FOLLOWING:11 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FORWHICH TM9 PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO NroRCFOR W COMPENSATION 1918AW$OF CALIFORNIA.' CONTRACTOR'S PERSONS WRING OR a SU"ONTRACTENG BN3NA RE CEITTIFIE8 THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY pERBpNB SUBJECT 70 WORKMAN'S COMPENS N LAVYS OF CALI ' THE �Tmvs ALL 24 HOURS IN ADVANCE FOR ALL REOUIREO INSP'E/CTIONi. COMPLETE pMVINO BELOW- 816NE TITLE: DATE: PLOT PLAN IDMW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOM SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSIONION F SEWAGE THINDIGRADIUS SYSTEMS. 3. DIMENBroNEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. to OF WELLS WITHIN MpIUB OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY• ..... --.. 1. ...1. ........... .. - ...... .,......-.., ..., _ - .. ... ......... ---., . � . s'` SMS r� ... any : .. ` :.... . : �o ..... ..... . _ � .. . J C •� ! pp�� nn 1�©u..2.�1 .... . PUE3L+C}tF}1lTH 5ER111 ES ... .... �NyIR()NMENTAL H1=AL H Dl '.............. ..',..,-..-- .,....,....,.._., ...i......'....,....... FOR DEPARTMENT UBE'ONIY APPLICATION ACCEPTED BY Ar DATE: AREA: Af TANK,PTT OR SUMP INSPECTION DATEFINAL INSPECTION DATEI� l�S�3 ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID) FAC# PE CODE FEE INFO AMOUNT REIMIITED CHECKNICASH RECEIVED BY DATE OR I PERIMT NUMBET INVOICE# I I Pub,Health Serv.-ERviro.174(,"1,)