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;APPLICATION FOR LIQUID WASTE PERMIT / "D. SAI./;,APPLICATION COUNTY PUBLIC HEALTH SE )CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 ��I •� f � ON-REF_UXDABLE_PERMiT-EXPIRES 1-YEAR_FROM_DA_TEISSUED ICBmpFBa In TripRaud APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1110. TH ARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH B RVICES,E RONMENrAL HEALTH DIVISION. JOB ADDRESSJOq DPN/ [� CRY O LOT SIZE OWNER'S NAME �I ADDRESS tJ 110.E?3tr CONTRACTOR .JC ADDRESS LK:a PHONE SUR CONTRACTOR ADDRESS LIC• PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ OESTRUCTRON ❑ - (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF DUILIXNG.I PERC TESTIQ L 1 NOW MANY �// APd�Uon a INSTALLATION WILL SERVE. RESIDENCE lel COMMERCIAL 11OTHER 13 E NUMBER OF LMNG UNITS: NUMBER OF BEDRO07 - NUMSEH OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: d PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKAWEASE TRAP ❑TYPE/MFG !A� CAPACITY dIA94V NO.COMPARTMENTS PKO TREATMENT PANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SLS AND OIL SEPARATOR(ENCLOSED OYBTEMI .1p � LEACHING LIME ❑ NO.A LENGTH OF LINES /7'� n 1 V DISTANCE TO NEAREST:WELL NDA LINE FILTER BED 0 WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL N UNE MOUNDED C}WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUND N PRD LINE SEEPAGE PIT$ ;Z9EPTH SIZE [? NUMSEFL=DISTANCE TO NEAREST:WELL _ !G A PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROFEFITY UNE DISPOSAL PONDS ❑wm 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 WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANDREQULATIONS OF THE BAN JOAQUIN COUNTY,HOME OWNER ORLCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:11 CERTIFYTHAT INTHE PEWORMANCE OFTHE WOO(FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HFNNO OR SUBdCONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIN PERMIT 1916"0.1 SHALL EMPLOY PERSONS SUBJECT TO MAN'S CONFERS ION/AWB OF AL1 A.• TH CANT MINT CALL Z4 NOMiN IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW, SIGHED X TRIS: O W h P✓ OATE: PLOT PLAN{DRAW TO SCALE)SCALE_ •to 1. NAMED OF STREETS OR ROADS NEAREST TO OR ROUNDING 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 SYSTE 0. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS OUCH AS PATIOS,DRIVEWAY8,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. i - .. .. - ..... .... .. I ..., :. ..,.. _ ... .... r� :..... ........... .. ...: .,....... .. .. .....-.,,-. :,. .. ` Al V ma � .......21: �X. .. .... .... . +` 4� o� ......:......... :. .... ..�i7.. " - .... ... PA ,M.ENT .... ....... .....:.. ..... :. .. . _ a F N /n'7f/�� SAN-JtJACIUNd ©iN17 . : r� h 4 RQNMENT/U HIxAiTH ECEB '.. ..'. .......:.... . .. ds olvlsipN ..,� EPARTMETIY_USE ONLY APPLICATION ACCEPTED BY DATE: '} AREA:,�,� TANK,PIT OR SUMP INSPECTION BY the IDAT ��-G - FINAL INSPECTION DATE a 4Zn 3; ADDITIONAL COMMENTS: ACCOUNTINO ONLY: AID# FACS PE CODE FEE INFO AMOUNT PAM11ED cNECKaICASH RECOVID BY DATE SR I P91MIT NUMBER INVOICE a Pub.HeBRh Serv,-Enviro,174(,WS)