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(_ ;?PLICATION FOR LIQUID WASTE PERMIT SAN .IOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)458-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED )£@mpl@te in Mpketa) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WrIH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 10.3 AN EI- D T STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. RDI ONMENTAL HEALTH VISION. 1 JOB ADORE8810R APNI 06 '` CITY LOT SIZES ` OWNEWSNAME ADDRESS PHONE CONTRACTOR_, � ` -_`.-----ADDRESSLN:/ .rr.4 f SUB CONTRACTOR ADORES TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPABUADDITION ❑ DESTRUCTION (No SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESThI I i HOW MANY AppBo""I . INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALS OTHER 13 NUMBER OF LR/ING UMTS: NUMBER OF REDROOM8: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITIBUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT RANT[3 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑•�SEIZZEE TYPE OF PUMP BAND OIL SEPARATOR[ENCLOSED SYSTEM) LEACHING UNE .S LENGTH OF LINES �� J DISTANCE TO NEAREST:WELLCQ � r FOUNDATION l'f::' PROPERTY LINE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE LETS ❑DEPTH SIZE NUMBER DISTANCE TO NEARE@T:.WEU_ FOUNDATION PROPERTY UNE SUMPS ❑WIDTHLENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS [3WITH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE - I HEREBY CERTIFY THAT I HAVE PREPARED THIS ATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REG U NS OP THESAN JOAOVIN COU .HOME OWNER OR LICENSED AOENT,S MONATURE CERTIFIES THEFOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FORWHICH THrAlrrl I BBVED HA T EMPLOY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'@ COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'@ HIRING OR SU A MIES THE OWING?'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOKS FOR W RICH THIS PERMIT IS 199MD,I SHALL EMPLOY PERSON@ SUBJECT TO WO C FE LA OF CALIFO THE APPLICANT MUST CALL 24 HOU S IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW�SIO o TITLE. V DATE• PLOT PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROAD NEAREST TO OR BOUNDING THE PROPERTY• 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH ERECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, G. LOCATION PROPERTY WELLS WITTING RADIUS OF ONE HUNOREO flf'I'Y FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS. 77 ...... ....................:. ...... ......... ......, - . ... THE $Q [ , y . ..... ["� ... 11�...: �.. 1 .. . ...... ..... ... ,.: .. 'wry .. C� FOR DEPARTMENT UBS ONLY PtEO BY DATE: 1.1� A A:- - Pub, ACCE , TAMC,ITT OR SUMP INSPECTION BY DATE_ I I FINAL INSPECTION BY E ADDITIONAL COMMENT B: C �L.c_,�_ �' '�� ett O•�--+, ACCOUNTNO ONLY: MDI FAC# ' PE CODE FEE INFO AMOUNT RE�OITEO C) fCA8H RECEIVED BY DATE 6101110101' IIT NUMBER INVOICE I � t u - J 2ai •Z Pub.Health Serv.-Erlviro.174(3196)