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APPLICATION FOR LIQUID WASTE PERMIT ,. SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmplata in Triplkattl) APPLICATION IS HEREBY MADE TO THE SAN JOAOUn4 COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 0-1110.3 AND THE STANDARDS OF SAN JOADUIN COUNTY PUBLIC HEALTH SERVIC E8.ENVIRONMENTAL HEALTH DIVISION. /` JOB ADDRESSOR APN"/'� n D —2—(02— /r� �//f - CfTI' � ��"t�/�6'1 LOT SIZE/Pj OWNER'S NAME �•�.YL. [ Cyto EI-, 1.--.� i ADDRESS P. C ! �1Z' �"T PHONE !2 -S I CONTRACTOR ADDRESS L1CJ PHONE BUB CONTRACTOR ADDRESS LICJ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF SUILDINGJ PERC TESTtil[ I HOW MANY Appllo�tlon J INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL 91 OTHER ❑ t7 i I NUMBER OF LING UNITS: NUMBER OF■EDROOMS: NUMBER OF EMPLOYEES: E L„JE I, CHARACTER OF SOIL TO A DEPTH OF J FEET: PIT7SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIaREASE TRAP ❑TYPE/MF(3 CAPACITY NO.COMPARTMENTS - 'Y PIKG rRFATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING LINE ❑ NO.•LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE — MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY 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 AND REGULATIONS OF THE BAN JOAQUIN COUNTY.NOME OWNER ORLICENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO;'I CERTIFYTHAT INTHE PEFFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOTWIA.' CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALJFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. � SIGNED X TITLE:� < DATE: GI 14 PLOT PLAN)DRAW 70 SCALE)SCALE_ 'to I Q 1. 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. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION Of WELLS WITHIN RAIXUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ..... . ... s , 7 Q R.. . Co .. .... �° cl -- �� - DEPAP.TMENTNLY APPLICATION ACCEPTED BY DATE G v AREA02-'� TANK,RT OR BUMP INSPECTIDji BY DATE 1 I FINAL INSPECTION BY - iLRATE ADDITIONAL COMMENTS:T ACCOUNTING ONLY: AID/ FACJ K FEE INFO AMOUNT REMI ITED CNECKI ASH RECEIVED BY DATE SR/PERMIT NUM98K INVOICE J �� — 3 54 Pu�b�.jHea�lth�Serv.-Enviro.174{3)96) �� ;Y- � � I � � �