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APPLICATION FOR LIQUIQ WASTE PERMIT SAN'10AQUIN COUNTY PUBLIC HEALTH SERVICES I4 ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, NX EAST WEBER AVENUE, STOCKTON, CA 9,,? X988 I a (209) 408.3420 ROK-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDlComPI REPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRIUCT AND/ORts In INSTALL JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUANTY PUBLIC HEALTH SERVICES,ENVIRONMEDESCRIBED. THIS INTAL HEATH DIVISION. WITH SAN JOB AODRESSIOR APNN t CITY_�, LOT SIZE 1 OWNER'S NAME 111 ! � ADDRESS ��_�� PHONE }� CONTRACTOR - 3 C l� ADDRESS a SUB CONTRACTOR LIC/'�PHONE S� ADDRESS , UC/ PHONE TYPE OF sEPnC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TE$TfH I I HOW MANY INSTALLATION WILL SERVE: RESIDENCE��OMMERCIAL ❑ OTHER❑ APl+llaetfon I NUMBER OF UVINO UNiTs:�^ NUMBER OF BEDROOMS; � ) NUMBER OF @HPLOYEES: 4 CHARACTER OF SOIL TO A DEPTH OF 3 FEET: �1�. PLTISUMP 801L CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS GO PICO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT sTAT1ON❑ SIZE TYPE OF PUMP 1 1�`'� SAND OIL SEPARATOR IENCLOS£D SYSTEMI —` C� LEACHING UNE ANO.h LENGTH OF LINES__. "f 0 018TANCE TO NEAREST;WELL�o FOUNDATION FILTER BE6 ❑WIDTH LENGTH •• PROPERTY LINE_ U DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED 1❑I��WIDTH�-• -IENOTH DEPTH -�- uroEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION �PROPERTY LINE�� , SEEPAGE FITS - - �^p1eTANCE TO NEAREST:WELL FOUNDATION70 PROPERTY LINE J n SUMPS ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS Q MOTH 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 R£OULATIONS OF THE SAN JOAOUfN COUNTY•HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 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 CAUFORNIA," CONTRACTOR'S HIRING OR SUB NTRACTIN4 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS 8UBJECT 70 SUB COM S' LAWS D ICAC ORNIA.' THE APPUCANT MUST CALL x�HOUM IN ADVANCE FOR ALL REQUIRED INBPECTIONs. COMPLETE DRAWING BELOW. r �1 SIGNED TITLE i DATE: PLOT PLAN IDRAW TO SCALE)SCALE •m 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. 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,O AYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. �r :. .... .. )C/-5 ,ci 5....:. U :a 1NL: : . ... . : . .. . PAYA dENT :. . ..... . . .... .. ..... : 9Pulg1 NIE t . .hNVlFlp !!C H ..'.......:. . ....... : CD.. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY AREA: TANK,PIT OR SUMP INSPECTION BY I E ?— FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID/ FACN PE CODE FEE INFO AMOUNT REMITTED CHECIGI A6 REC91VED BY DATE SR J PERMIT NUMBER TRVOICE/ v70