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APPLICATION FOR LIQUID WASTE PERMIT N JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION # 304 EAST WEBER AVENUE, STOCKTON, CA 95202 `," n (209) 468-3420 3 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Compute In Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN 1IOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CH I�ER 9.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOS ADOMSSIOR APNf__J2 1..1 6 r: /W" ere - ZJ " CY LOT SIZE OWNER'S NAM F9 YC II O. 004 ,. ADDRESS_ �(�� Q. C Pyr-h,U PHONE CONTRACTOR ADDRESS LICE PHONE ) SUR CONTRACTOR ) ADDRESS LICE PHONE TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIRIADbITION ❑ _ DEOTRUC ' [NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI)t 1 HOW MANY y Appllaatlen/ INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ 'i NUMBER OF LIVING UNITS: NUMSER OF BEDROOMS: NUMBER OF JAAPLOYEFA: CHARACTER OF SOIL TO A DEPTH OF 3 FEET:�II PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/A VASE TRAP EI1'YPEIMFG CAPACITY NO.COMPARTMENTS ii PKO TREATMENT PLANT,El DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE Il LIFT STATION D SIZE '.TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING UNE ❑ NO.h LENGTH OF LINES DISTANCE TO NEAREOT:WELL FOUNDATION PROPERTY LINE FILTER SEA ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDAT)ON PROPERTY UNE SEEPAGE RTS ❑DEPTH ii SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BUMPS 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE � DISPOSAL PONDS ❑WIDTH LENflTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THI9 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REO ULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR UCENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE MAK FOAVVMCH THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY�'ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORN)A.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IB MSUEM I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CARL.24 HOURS IN ADVANCE FOR ALL REIIUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED TITLE:_/1J/1.r'/ DATE:._ i '[ PLOT PLAN(DRAW TO SCALE!SCALE_ to 1. NAMES OF STREETS OR ROADS NEAREST TIO OR BOUNDING THE PROPEMY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,VVRH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF AUR EXISTINO AND PROPOSED STRUCTURES. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,11111VEWAYS,AND WALKS, THE PROPERTY OR ADJOINING PROPERTY. ..,., ,....,.,..., ..... .. . ........ .,... - - -..--.. .. .. .. .. ., . .'„ . ....... ... � . SIA , . ... . .. ...... .. _ . ........ ll1 �, t r 3,. �, .�. ffr;4r .. . ..: .. . ...:... S �:. ... 3. . . - - = ..... , 1 < -In r,•, PUi' i iVl{`F'r w .. ...... / X . ...,... IIP J3'e NVIRC�Ntii�II V S�if I rH i?1VI�Is C .: .. . II - r, J F—I. Iba .... V9 . ... .. l . ' ........... .......... .. .. ...,.. >,. .. .... ..,.,...-.. - .. .. .,. FORD ARTMENT USE ONLY �/�/"/�C'1 APPLICATION ACCEPTED BY DATE; ( AREA: �L " �]�J TANK,PIT OR BUMP INSPECTION BY � DATE , ! ! FINAL INSPECTION$Y � � /% DATE , C ' ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDf�i FACE ' ! PE CODE FEE INFO AMOUNT R.kMHTED CIIEc ASH RECEIVED BY DATE. SR I R3�MIT Nt"BER INVOICE I —dub.Health Serv.-Enviro.174(3/96) CL i