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--�PPLICATIOH FOR LIaUIO WASTE PERMIT <br /> SAI. JAOUIN COUNTY PUBLIC HEALTH SE CES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 [ �/ <br /> (209) 468-3420 <br /> NON-REFUNDABLE FERMIJ EXPIRES 1 YEAR FROM DATE ISSUED <br /> IC/IBpIBt/in Triptkatd <br /> APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MAGE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11111 t.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.EN NMENTAL HEALTH DIVISION. <br /> JOB AOORESBIOR APNFER' / CITY f�N LOT SIRE <br /> OWNS NAMEr ADDRESS �hn PHONE <br /> CONTRACTOR ADDRESS LICI PHONE <br /> LICN PHONE <br /> SUB CONTRACTOR ADDRESS <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION❑ <br /> E <br /> (N0 SEPTIC SYSTEM PERMITTED IF PUBLIC HEWER IS AVA LABLE WITHIN 200 FEET OF BUILDING.) PSRC TE91W 1 I HOW MANY <br /> Appff—den/ <br /> INSTALLATION WILL BOWE. RESIDENCE% COMMERCIAL❑ OTHER <br /> NIMMSER of LIVING UNITS: NUMBER OF B OMS: N�MSER <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: /BUMP BOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANKNOWASE TRAP ❑TVPEIMFn CAPACITY Zdgn2 mgromPV 17 <br /> PKO TREATMENT PLANT❑ DISTANCE TD NEAR T: WELLFOUNDATION LIN <br /> LIFT STATION 1 SI c TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED BYSTEMI <br /> LEACHING LINE 1�.C.,J/NO.S,LENGTH OF LINES DISTANCE TO NEARE8T:WELL AT PROPERTY LINE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION 01-PROPERTY LINE <br /> SEEPAGE FRTB DEFT4 e `SIZE�NUMBER_DISTANCE TO NEAREST:WELL /Z C FOUNDATION la PRDPEIDY LINE <br /> SUMP/ ElwDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> 1 HERESY 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 <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATUTIE CERTIFIES THE FOLLOWING:'I CERTIFY THAT INTHE PERFORMANCE OFTHE WOW FORANKH <br /> THIS PERMIT IB ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO VMFIKmAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> 8U8-CONTRACTING SIGNATURE CERTIFIES THE 04 AM:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAH'8 COMPF ATION LAWS OFC A.' THE ANT M T CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTION/. COMPLETE DRAWING BELOW <br /> SIGNER TITLE: ate/„///BJP✓ DATE: I <br /> PLOT PLAN[DRAW TO SCALE)SCALE 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYBTEMS. <br /> 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> ..... - -. _ _ .. '..... .. - .. <br /> 00 <br /> .... ..w, � :. Cif <br /> r ... <br /> :. <br /> I <br /> :IL ' <br /> ;....AYM . <br /> RECEIVED <br /> . <br /> :...NOS 19 <br /> SAN <br /> PUgGCOEOARTIN C Ull S <br /> � <br /> .......>...,.`... . ... ., � <br /> ENVIRQNM9NTAL. LEAL1H DIVISION <br /> - 'r- _ -FSR. AR7MEN7 USE ONLY --7 .� <br /> APPLICATION ACCEPTED BY <br /> A DATE+ �� �s �A• -- <br /> TANK.PIT OR SUMP INSPECTION BY DATV191 FINAL INSPECTION DAT�a 1,4ta" <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTMO ONLY: AID! FACS <br /> PE CODE TEE RNFO I AMOUNT REMIITED CHECIV/CASN RECEIVED BY DATE OR I PERMIT NUMBER INVOICE f <br /> s� Is c7W 41 <br /> Pub.Health Sere.-Ewro.174(3/96) <br /> fir. ��� r-z <br />