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APPLICATION FOR LIQUID WASTE PERMIT . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA SSM.-M ROS) 488-3420 IKON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IB NEWBY MADE TO THE BAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,,CHAPTER 8-1110.?AND THE STANDARD OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENNNVVN30NMEWAL HEALTH DIVISION. , POR ADDRESS/OR AMAAti 0 _J JA-Z,06 _ CITY'.[$�CL� LOT SIZE O0TP OWNER'S NAME y--, ADDRESS D PHONE — CONTRACTOR �ADDRE8S1 PHONE SUBCONTRACTOR 4 AOPRF.66___ Il C1 FWONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAImADdiION DFSTIIUCTION ❑ (NO SEPTIC SYSTEM PERM"M IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF SUILDING.1 PBIC TEeTIN l I HOW MANY �, /' APPIIPA8011 f INSTALLATION WILL SFRVF. RFSIorw.l « c,l MFR n:r: Lo!o! / OTHER E] NUMSIGR OF UMNO UMR e: _ 7,111061-117,111061-11IIF BEDROOMS NUMBER OF EMPLOYFFB::—j--_ V` CHARACTER OF SOB.':n A DFYRH OF J iFEi._ I MiSUMP BOIL CHARACTER:—WATER TABLE DEPTH AEPTIC TANKIGRFABE TRAP ❑T'PINIF _ CAPACITY _ NO.COMPARTMENTS `I PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL. FOUNDATION PMPERTY UNE MET STATION❑gS,IZZEf MP es TYPE OF PUMP/ F_BAND OIL SEPARATOR(ENCLOSED SYMENG A� L f (J /� F LEACHING UNE NOUf .LENGTH OF LINES 4 DISTANCE TO NEAREST:WELL Ki FOUNDATION PROPENTY UNE_[= FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE S MOUNDED 13 wwH_LENGTH_DEPTH DISTANCE TO WARIEST:WELL FOUNDATION F PROPERTY LNIE�_ C ca PEEPAOE RT M DEPTH, SUE -311n _NUMI DISTANCE TO NEAREST:WELL i 50 f FOUNDATION PiWRTY LINE PEt*-) SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE V DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE �. 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAW$,AND RULES AND REGULATIONS OF THE SANJOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THEWORK MRWHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR N' SUB CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'I 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 CALIF THE APPUUCAlAil4T A1UST CALL 2A HOURB IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED% / -/ ( L:O I�>�2�Xi// TITLE: �Y 7/ DATE: I 1—! SLOT MAN IDRAW TO SCALE)SCALE -M I. NAMES OF STREETS OR MADS NEAREST TO OR BOUNDING THE PROPERTY. e. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ]. DIMENSIONED OUTLINES AND LOCATION OF All EMITTING AND PROMISED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXB. THE PROPERTY OR ADJOINING PROPERTY. o IDP 1 ex /Ne , ) I d�lO�fiN�Pk j�oV 41996 i FOP DEPARTMENT USE ONLY 1 Lf/�F-- APLK ATION ACCEPTED BY /' OATE:�1�[:" / / AREA: � � S TANK, T�R SUMP INSPECTION BY / DATE) I I L INSPECTION BY-T E � ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIG/ FAC/ PE CODE FEE INFO AMOUNT REMITTED HECK ASH RECEIVED BY DATE SR I PHOT NUMBER INVOICE 0