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APkCTION FOR LIQU D I WAST E PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED (Complete In TFipikatel 'PLICATION IB HEREBY MADE TO THE SAN JOAQUIN COUNTY FOA A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAN >AQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. I r /- B ADORESBIORAPHI !, ' D d' CITY /t!"�r� - - _ LOT S1ZE , VNER'B NAM[ ress�Il p C- I ADDAESS_,/,�/_2 Zak Z20 C[r/71�w1T _.._ PHONE /S/ iNTRACTOA � ADDRESS LIC# PHONE .B CONTRACTOR I! ADDRESS I LICE PHONE PE OF REPTIC WORK: NEW INBTALLAGION '❑` REPAIRIADDITION ❑ DEIITRUC l SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDINO,) TF1TIt)I )HOW MANY ;TALLATION WILL NERVE: AESR)ENCE❑ COMMERCIAL 11 OTHER 13 _ 1 M1301 Of M OF WINO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEEN: M - ACTER OF SOIL TO A DEPTH OF FEET: MISUMP SOIL CHARACTER: WATER TABLE DEPTH y 'I MC TANKMREASE TRAP 13TYPFJMFO I� CAPACITY NO.COMPARTMENTS I TREATMENT PLANT❑ DISTANCE TO NEAREST. I' WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) J I I fljJ CHING LINE ❑ No.&LENGTH OF LW LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE EA BED ❑MOTH LENGTH I� DEPTH DISTANCE TO NEAREST.WELL FOUNDATION PROPERTY UNE AYDEA ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE PAOE RTS ❑OEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 11'5 ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 'OVAL PONOS ❑WIDTH LENGTH i DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE - IEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DYNE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT-S SIGNATURE CERTIFIES THE FOLLOWINO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH PERMIT IS ISSUED,I eHALL NOT EMPLOY ANY PERSONIN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO KMAH'S COMPENSATION LAWS OF CAUFORNIA.' THE;APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPLETE DRAWING BELOW. ED 'yy TITLE: /9L�Lr.1/'/ DATE: / l PLOT PLAN IDRAW TO SCALE)SCALE_ 'to h AMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED UTLINE OF THE PROPERTY,MIN DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. F II,MENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON ,r YUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. a ..i..... ........ ..`.. -. ... .. ... ... .. .- .. .... - S ....:. .,', .....,. ......,...........:,.... L.......... ......:. ............... :.,., .:. .. .. ., .. .. I ...... . ...... .: .. 3 yv-,G}� t y, -,. .., .... T. k ...... t NVIRC�N�� Inti F �,.....?...... ...,:.... .. .. ! IH i . . ., .....,. .. . : V V ..,.. I ..: . .....;. ...... .. . ,...... .: .... ....... ..., .. .. - -- .. .... .. - -— - 111 r-- .. .........: . .. I ........ ....... `. ..... .. ...,..: .., 1 ATION ACCEPTED BY -� FORD ARTMENT USE ONLY � DATE: AREA; i 'IT OR SUMP INSPECTION BY lie DATE / ! FINAL INSPECTION BY f/' GATE /1 )NAL COMMENTS:_ I' _3 oVNT[NO ONLY: AID# �I FAG# - 'ODE fEE TNFO AMOUNT RETN11TEp CHl C ASH RECEIVED BY DATE BA!t'EAM1T NUMBER INVOICE I �I -7 / �'• I Health Serv.-Efrviro,174(3/96) I � � c C�fi D,