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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES �1 ENVIRONMENTAL HEALTH DIVISION P,(X BOX SM, 304 EAST WYEBEA AVENUE, STOCKTON, CA 95201 X88 1209) 488.3420 I i NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICompIAlA In Trl lkAtAi 1ZICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDlOR INSTALL THE WOF1L DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN IACUIN COUNTY DEVELOF"ENT TITLE,CHAPTER 9-1110.3 AND 114E STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH 6ERV1 ES, VIRONMENT L 14EALTII 01"SION_ 11UDRESSIOR Am# /° 1 // CFTY /IIVfJ L LOT SIZE ER'S NAME �L' -' 1 - C ADDRESS '/ 6 I °Y LlPHONE- ADDRESS1�14 ��,` �/ 1(J' LIC# PHONE / �ONThACTOR ADDRESS LIC/ PifONE PE OF AEPTIC WORK: NEW IN&TALLATiON ❑ REPAIRIADDITION DE&TRUCTION ❑ EF'TIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) FERC TFAT(-I I 1 HOW MANY I;TALIATIOTI WILL SERVE: RESIDENCE IJ COMMERCIAL ❑ OTHER❑ 11OF UVINO UNITS:_ NUMBER OF BEbiLOOMS; ~'_ S NUMBER OF FMPLOYEES: 110.,TEh OF 6011 TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH tTIC TANKIOREASE TRAP I]TYPE/MFO_ )( I, fEo _- 13*,•..►d�—._.,.•CAPACITY NO,COMPARTMENTS TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ 6IZE _'TYPE OF PUMPBAND OIL SEPARATOR IENCLOSEO SYBTEMI / ! ANG UNE NL9' p, LENOTIi OF LINES 7 DISTANCE TO NE AAE BT:WELL-�E/ —FOUNDATION_pT,OpERTy LINE TEA SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 11DED ❑WIDTH ,ENGT11DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE_ OF RTA p{PT}l� SIZE—3_ 3 L ..`NUMBER_/_DISTANCE TO NEAREST:WELL o FOUNDATION PROPERTY LINE _ SpA ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE AAt POND• ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE L�n I -BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES Io REGULATIONS OF TIIE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AOENT'B SIONATURE CERTIFIES THE FOLLOYNNor'I GERTFFY THAT IN TITS PEhFOIN . E OF 7HE Won(FOR W111GI! IIS PERMIT IS 16SVEb,i SHALL NOT EMPLOY ATPf PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOIWM,' CDNTMCTOR'B WRING OR MAN'S CTM NSAT SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE R'ERFO RMAIICE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS BUB.IECT 10 m MAN'S COMPENSATION LAWS OF CALiFd1fRE THE APPLICANT MUBT CALL 2A HOUR&IN ADVANCE FOR ALL REOUIRED INSPECTION@. COMPLETE DRA"nNO BELOW, ( 7 CNEa x 7 •,<� �J -rte i TITLE. DATE: 1' PLOT PLAN(DRAW TO SCALEI SCALE to f PIAES OF ST RESTS OR ROADS NEAREST TO OR BOUNDING 7HE PROPERTY. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 1. LOCATION OF HOUSE BEWAOE DISPOSAL SYSTEM OR I'hOPO6ED DIMEN610 NED OUTLINES AND LOCATION OF ALL EXISTING AND PltOPpBED BThUCTV11E6, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 6. LOCATION OF WELLS OINIIN RADIUS OF ONE HUNDRED FIFTY FT.ON LUOINO COVERED AREAS SUCH AB PATIOS.OF EXISTI G AND WALKS. THE PROPERTY OR ADJOINING PROPERTY, Ho v 4v ti �✓cam i.�+ : Jz)l-(io : boat FOR DEPARTMENT USE ONLY '111CAilON A1:f;E111TU OY -^I I C DAIS: C... AREA: RT 01{SUMP INSPECTION BY OATS ! ! FINAL INSR EC110N BY +-�. DATE 16N►iLCOMMTNt6: G rf vLE G I -^ r s ._..� �+ sJ ACC twom ONLY: AID# FAC/ CODE FEE AMOUNT REMITTED CHECKNICASH RECEIVED BY DATE AR/PEILMIT Nt1M6FR INVOICE/ p'ri y:w r