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211 • . - �,s 4,4PLICATIOX FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 f'c1 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lComploto In Triplicate) APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOWS DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WtIH SAN JOAGUUN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH)SERVICES.ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESGIOR APN# (I� DL. J "" ``1'1. 1'L CITY_ L c%,4 L? LOT SIZ& OWNER-S NAME Cep )aj ADDRESS PHONE CONTRACTOR��/ Ike -__ _ AODRESS !`� if'7�[` S� ._UC'o'_'z-QPHONE S SUB CONTRACTOR ADORES S LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDIT10N ❑ . DESTRUCTION D ANO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 1S AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIPI I I NOW MANY Appomilon f INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL(3 OTHER ❑ 'RQ� NUMBER OF LIVING UMTS..—L— NUMBER OF BEDROOMS:� NUMBER OF EMPLOYEES: - CHARACTER OF SOIL TO A DEPTH Or!fF-1 FFEE_T�:_ PIT/BUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKUTMIEASE TRAP LYPVMFO�t/�" '�'L. CAPACITY7)_)t n h _._NO.COMPARTMENTSP, PKO TREATMENT PLANT 17 DISTANCE TO NEAREST: WELL r z_ FOUNDATION_ PROPERTY LINE C� LIFT-STATION© SIZE TYPE OF P/U�UMP SAND OIL SEPARATOR MHCLOSED SYSTEM) 66 9 I EACHINO LINE U-NO.IL LENGTH OF UNESd-—L 4�` _ DISTANCE TO NEAREST:WELL��(��FOUNDATION _PROPERTY LINE, FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE��„^ SEEPAGE PttB EPTH SIZE NUMBER DISTANCE TO NEAREST:WELL t^n .FOUNDATION PROPERTY UNE SUMPe D WIDTH LENGTH DEPTH DISTANCE TO NEAREST.WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THEFOLLOWING:'1 CEFITIFYTHAT IN THE PERFOIOMANCE 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 CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SMNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUEO.I SHALL EMPLOY PERSO SUBJECT TO i WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL SECURED INSPECTIONS. COMPETE DRAWING BELOW. � SIGNED X C�'W`�. `V�� _TITLE: DATE: r . PLOT PLAN(DRAW TO SCALE)BCALE� 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PNOPERTY. 4. LOCATION OF HOUSE SEWAGE C49POM SYSTEM OR PROPOSED i 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION- EXPANSION OF SEWAGE DISPOSAL SYSTEMS. e. LOCATION OF WELLS WITHIN RAD1118 OF ONE HUNDRED FIFTY FT.ON 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYa,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY' ... .. 1� .. . ... .. . :.. i ... Ac .. . .;.. ..: b .. i . ...... _ ; 5 „ . d ... d Yf[ ..... 5C1 .. �I . :2 .. ... . :.: .� a .. , a .. ... r . ._ • - FOR DEPARTiNENT USE"ONLY.., APPLICATION ACCEPTED BY _ DATE: "'Y• t� 4 AREAt OR SUMP INSPECTIO14 BY - DATE ,�{ AL INSPECTION C DATE ADDITIONAL COMM.". i Py I ACCOUNTING ONLY: --AID# FACS PE CODE FEE INFO AMOUNT RM$TED I !CASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE IF r� Pub.HeaRh Serv.-ERviro.174(3198)