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APPLICATION FOR LIQUIII WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ti r ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 9 (209)468-3420 f fsr ROIL-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in T►iplints) ArPLICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN •[JOAGUni COUNTY TITLE.CHAPTER 10.3 AND THE STAND E.SAN AOUIN COUNTY PUBLIC C14 TH SERVICES:ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR # LOT SIZE `� OWNER'S NAME 'T� ' /y�.,�, ADDRESS �Y PHHONE g-/ � ' CONTRACTOR .�. r�[�'— i'� . -�-�v -1 ...__ADDRESS - LIC/ J r �0 pHONE SUB CONTRACTOR AItDRE58 LIC# PHONE I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION ❑ ANO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PE RC TESTNI I I HOW MANY .r.,� APPeOUIIOh/ INSTALLATION WILL SERVE: RESIDENCE ti COMMERCIAL ❑ OTHER ❑ NUMBER OF WINO U►BTS;�— NUMBER OF BEDROOMS „�_ NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 1 FEET:, PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANSJOREASE TRAP D TYPEIMFQ CAPACITY is NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION I/ PROPERTY LINE.Y UFT STATION D SIZE TYPE OF HUMP BAND OIL SEPARATOR IENCL.OSED SYSTEM) LEACHING LINE Irk NO.A LENGTH OF LINES ?��I DISTANCE TO NEAREST:WELL _jI C7 FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNEtz BUMPS D WIDTH ,d4./R LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION (7'— DISPOSAL UNE DISPOSAL PONDS 13 WMTH 7�`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 RULES AND REGULATIONS OP THE BAN JOAQUIN COUNTY.HOMEOWNER OR LICENSED AOENT'8 SIGNATURE CERTIFIES THE FOLLOWING:'ICERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT SB ISSUED.1 SHALL.NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'B HIRING OR BUB•CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING.'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WH1CH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO NORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPLETE DRAWING BELOW. ,. oBIONED X TRLE:_ fX'77 „ DATE: PLOT PLAN RDRAW TO SCALE)SCALE 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM O PROPOSED -Z. 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 WALKB, THE PROPERTY OR ADJOINING PROPERTY. ...;... . ....: .. .3.. .., ... ., ..: .. .:.......', .. ....:. .....,... .... .. .. .............................:_.... . :.:. �... •" ..............:....r;..... r.,..:....' .:....:.....'.......5......1......E.....:...,...E. .. rr {. �+.A " r 1 F-cot klz jag- 'PUEJOC HFA .. ..:,.. .... Ny??SJNR4EL#H SCF�Vf Y ;.. t ON .. _ ¢ µh y 4 A FOR D�ARTMEHr V4B0 ` ^+' a.,�:':e'' .1n ? ,)• Y�` K :.( .sPr 'a,� �, £ F +` ,..,..4 y ...«gy'y"�.w"''- t10RL'ACCEP.TED BY��` �a E.x. _ � OM K i sa Q.� �- ,...� ^. �,. �'�.•. �