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APPLICATION FOR LIQUID WASTE PERMIT ' PAYMENT .. SkN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED �:- ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202A� 3 ZOOD (209) 468.3420 1-Z L � �� RON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES (Complete In Triplicate) APPLICATION ENVIRONMENTAL HEALTH DIVISION JOAQUIN COUNTY DEVELO HEREBY MADE T TITTHE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND70R INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN ER 9-1110,$ANp T�DAROB OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �E�I h0!gqMMENTHEALTH DIVISION, JOB ADDREBSIOR APN# y� WF jrJ CITY �'pl��U/ L�✓I LOT&ZE OWNER'S NAME / ADDRESS I a'-4.L v PHONE CONTRACTOR ADDRESS w SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIIVADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERFAFFTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTlvl I I HOW MANY INSTALLATION WILL SERVE: RESIDENCO COMMERCIAL❑ OTHER ❑ NUMBER OF WING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3PIT7SUMP SOI CHARACTER: WATER TABLE DEPTH iEPTIC TANIUGREASE TRAP YP£IFAFfl ) CAPACRY V V _NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR{ENCLOSED SYSTEM) i LEACHING LINE / v NO.a LENGTH OF LINES 7V 4��r7 � DISTANCE TO NEAREST:WELL �'� FOUNDATION '-7�PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST.-WELL FOUNDATION PROPERTY LINE SEEPAGE PITS DEPTH SIZE NUMBER DISTANCE TO NEAREST.WEL�=FOUNDATION PROPERTY LINE 1 SUMPS 7773 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS °❑WIDTH LENGTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 4 7 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES j AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIED THE FOLLOWING:I CERTIFY THAT WTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PE NIH SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'S HIRING OR BUB-CONTRACTFNO SIGNATURE CERTIFIES THE FO O NG:'I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I8 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION 8 OF CAU I THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INfPECT1hOONS. COMPLETE DRAWING BELOW. f tC'1j 15k ` IRONED X � TITLE: DATE: — PLOT PLAN DRAW TO SCALEI SCALE •t, 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING 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 INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. i .... ..... -- .... .. .. - :. .. .. .. .. .. .. .. ...,... ., ...: i .. - -. ............. 1 .,.. ... _ .. .. .. .. .. - ... .. �... :... ..... .. .... ... ... .....A :. .. .:. e .... ..;. .. ...: . . .. . 1 i . ... .... .. .. - . .. .. - r � FOR D TIENT USE ONLY C1c APPLICATION ACCEPTED BY DATE: AREA: TANK,PIT OR SUMP INSPECTION BY DATE_ ! ! FINAL INSPECTION BY DATE !I f ADDITIONAL COMMENTS:-_ ACCOUNTING ONLY: AIDS FAC# PE CODE FEE INFO AMOUNT TIPAITED CIIECK# ABH RECEIVED BY DATE SR 1 PMWIT NUMBER INVOICE# Pub.Health Serv.-Enviro.174(3/96)