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APPLICATION FOR LIDUID WASTE PERMIT zmN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES- ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 962010388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# 531-7 tit/ G-t 4 ry t 4 I Av Q ' S CITY ( r c'-h LOT SIZE I} KILN'S OWNER'S NAME 'GS(.l!'d N Q r Tr K/NQ ADDRESS S 3 / 7 L� ' U-r CIN/ IA/ ? jiYd PHONE CONTRACTOR_ [}t.tY/V Z^ ADDRESS UCN PHONE SUB CONTRACTOR ADDRESS UCS PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.( PERC TEDTUI 1 1 HOW MANY ADdlosSon f INSTALLATION WILL SERVE: RESIDENCE 1:1COMMERCIAL OTHER ❑ NUMBER OF LIVING UNITS: NUMSER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OFFl 33 FEET: 1 PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH /M SEPTIC TANK/OREASE TRAP yr TVPEFG 'rA CI+FL C Q NCYI T` CAPACITY I�L O1 NO.COMPARTMENTS SEPTIC TANKIOMASE TRAP 0 Z �� WO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY'UNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING USE ❑ NO.S LENGTH OF UNES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UN£ FILTER BED ❑WIDTH LENGTH —DEPTH DISTANCE TO NEAREST:WELL—FOUNDATION—PROPERTY UNE— MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL_FOUNDATION PROPERTY UNE_ SEEPAGE WT$ ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE .n SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE _ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO NG WORKMAN'S COMPENSATION LAWS OE) �RNIA.' THE APPl1CPNT MUST CALL 34 HOURS IN ADV TITLE:FOR /Vim'REQUIRED ICOMPLETE TE DATE:I�BEL��—�� SIGNED —#_ J ROT PLAN(DRAW TO SCALE(SCALE 'to D. 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. w ttC pro ptet t ►N{ R.onn. e .n r INe M uj T4N K QP ! Ir -QN K p¢ct arz� 0/V4sl -1-r1-41C� / �e1 tic• G' — PAYMENT RECEIVED JUN 2 3 1997 SAN JUAUUIN C.lUNT) IJ 1 PUOUC.HEALTH GERViCES ENVIRONMENTAL HEALTH DIVISION IIr4Nr L IINP K> 1 I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY C V RJ �X'L^(�`/a—� DATE: AMA:�i ,D�f-D TANK,PLT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY c°Ul- A+-P/✓rr DATE �� /Z 47 I ADDITIONAL COMMENTS: , L ACCOUNTING ONLY: AID( FAC# PE CODE FEE INFO AMOUNT REMITTEDL4HECJE/CASH RECOVED BY DATE SR I PERMIT NUMBER// INVOICE F i J J 7