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APPLICATION FOR LIOUID WASTE PERMIT SXN JOAQUIN COUNTY PUBLIC HEALTH S-LAVICES O ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 Y (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CamPl'ta In Triplicate) APPLICATION IB HEREBY MADE TO THE SAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT ANDOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN 10AMIN COUNPY DEVELPM TITLE.C AFTER 9-1110.3 AND THE STAIDJURDS OF BAN"97 )TH AOUIN C NTV POBUC HEAL-HHH SERVICES.ENVIRONMENTALIVISI HEALTH DON. 100 ADDRESBV I C" V ' LOT SIZE //�� OWNER'RN _ ADDRESS14-69 CZW W (L ,'o {/l\R05 t PHON V 71 CONTMCTO ADORES6 A UCa�]_PFION 07 SUBCONTRACTOR ADDRESS LIC, PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESINI I 1 HOW MANY INSTALLATION WILL SERVE: RESIDENCE ❑ COMMEEC1AL� OTHER ❑ NUMBER OF UVING UMTa. NUMBER ROO'+F//BEDROOMS: ' NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OFF�3(FEET:—F'1 N )J PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ,6J lPUMF —Vr CAPACT' /� NO.COMPARTMENTS PSO TREJLEMENT RANT❑ DISTANCE TO NEAREST: WEL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSEO SYSTEM) LFACHHO UNnE ❑ NO.• OTH OF UNTO DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE RLTER BED A/ �WIDTH L 1 LENGTH DEPTH DISTANCE TO NE .T:WELL FOUNOATbN�RroPERTY UNE MOUNDED ///�� ❑WIDTH LLNOTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH__SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDAMN PROPERTY UNE DISPOSAL PONDS ❑WIDTH 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 BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND WOULATION9 OF THE BIW JOAMIN COUNTY.HOME OWNER OR LICENSED AOENT'9 SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY AVIV PERSON D SUCH A MANNER AS TO BECOME SUI IECT TO WVRKMAN'8 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR-0 HIRING OR SUBCONTRACTING MNATURE CERTIFIES THE FOLLOWPNG: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMA/N''SS CC�OO�IMPEENIBBBAT EI L■�AWB OOFCALIFORNIA.-1THE APPLICANT MUST CALL 34 HRMS IN ADVANCE MR AAA 11M REQUIRED IN(ILSL�PECY,TIIOOL1N'. COMMETE DMWINO BELOW. SIGNED L`( _Y 11 1/ L • l/' /1 O / TNLF' Y I IJAn tM ATI'97-2 ROT RAN IDMW TO SCALE)SCALE_ IP 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDINO 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 BYSTE68. 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 ADMININO PROPERTY. nec,L'� Its tNVul 'i ) _ i i f'.ntR, VMDJs..oansu un,c.. I ti 2ow /�,� -'T�� v XJEX�OLIfOCYJL-IEGu y- GAL- V "4-- �sy�aA�s�PJ HSP Ern 0 o r Lf��P��Q ` Pmklti�nr'Slfi,��'�YPr). Eu JU Vu it" UMI ""- rUaIJCPEAU f:WIC I{{\(Z�� ENVIRCINMF"k , 1 PIF rl').E`�. T' I APTM _.____..___,...,... .,.._,_..APTN.....,......:-......,.w..wwrevc,wcZ/Pml. DE' FHT USE ONLY APPLICATION ACCEPTED BY �%YY /rl 7/7T/A IIIIIAL� GATE: / AREA: TANK.PIE OR SUMP INSPECTION By DATE _ / / FINAL INSPECTION SV DATE 1 �-1 ADDITIONAL COMMENTS: A (/l'/t � �� /6��ry� "' •- "IS �L��"' O •`'C� >fl VV/ ACCOUNTING ONLY: AIDS FAC, PE CODE FEE INFO AMOUNT RFMIITEO ITEC CASH RECEVE2BY DATE aR/PEMITNUMMER INVOICE L!S 25 01 6' SR Pub.Health Sere.-EnvgO.174(3/96)