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(-91PPLICATION FOR LIQUID WASTE PERMIT SAI ..-OAQUIN COUNTY PUBLIC HEALTH SE , ICES ENVIRONMENTAL HEALTH DIVISION_ �(��" 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUN11AKE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iCampkto In Tripkatld 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 9-111 .3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,EN NMENTAL HEALTH DIVISION. JOB ADDRESSIOR APNN Pi CITY C' LOT SIZE OWNER'S NAME ' ADDRESS IraPROM CONTRACTORPIT ADDRESS LICP PHONE SUB CONTRACTOR ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION IIEPAIRIADDITION ❑ DESTRUCTION❑ W SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING-1 PIERC TESTER I 1 HOW MANY Applaaftn I INSTALLATION WILL SERVE: RESIDENCE IQ COMMERCIAL❑ OTHER❑ NUMBER OF WINO UNITS: NUMBER OF BEDROOMS: r� NUMBER OF[EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET PIT P L CHARACTER: ;KWATER TABLE DEPT SEPTIC TANXXXWASE TRAP ❑TYPFJMFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERWUNEIE UFT STATION❑ SIZE TYPE OF PIMP SAND OIL SEPARATOR IENCLOSED SYSTEM; ��yLEACHING UNE ❑ NO.•LENGTH OF LINESDISTANCE TO NEAREST:WELL �J V U A LINE FILTER BE) ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLUNDAPS LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST-WELLPERTY LINE SEEPAGE PITS ❑DEPTH Ilk NUMBER DISTANCE TO NEAREST:WELL „ FOUNDATgN PROPERTY LINE [� SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST-WELL FOUNDATION PROPERTY LINE \ 1 DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I 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 fRRULEB� AND REGULATIONS OFTHE BAN JOAQUIN COUNTY.HOME OWNEROR LICENSED AGENT'S SIGNATURE CERTIFIESTHE FOLLOWING-'I CERTIFYTHAT INTHE PERFORMANCE OFTHE WORK FOR' HICH THIS PERMIT TB ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WOIKMAN'B COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'8 HIRING OR //�� SUB-CONTRACTING 91ONATUPE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TH18 PERMIT$a ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO� WORKMAN'S COMPENSAT LAWS OF CALIFOIWI ' THE N1 MU8 CALL 24 HOURS IN AIYVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X r TITLE: DATE: PLOT PLAN(DRAW TO SCALE]SCALE le 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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 SYSTEMS. - 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES• S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON t J INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS- ININGPROPERTY .,., .... _ _ _ ., _ _ - THE ...... .....:. .. ..; ... / �.. ...., .r R: ..... :. ... . fo . .. .. r7. N' ell: ;.... . 1 :.. . .. .. .... ...... .... .. ... 29�9�9 1 �'N HSA 7IN COIrIv fY _: . SEiiVlirE"S N7AI,HEALTH OivmloN--; .' ......... ..... a S....:. .. ... ....... FOR DEPARTMENT U8S;ONLY APPLICATION ACCEPTED BY DATE: AREA• III TANK,PIT OR BUMP INSPECTION SY T� INAL INSPECTION B ATEit ADDITIONAL COMMENTS: F r ACCOUNTING ONLY: AID& FAC40 PE CODE FININFO AMOUNT REMIITEB ClIECKFICASN FI EC BY DATE SR I PERMIT NUMBER INVOICE o - 03 z Pub.Health Serv.-Errviro.174(3)96)