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APPLICATION FOR LIQUID WASTE PERMIT <br /> AN JOAOUIN COUNTY PUBLIC HEALTH SERVICL. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 4883420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P.MOP�UA. <br /> ICampl*t* in Tripli*u*I <br /> APPLICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOW DESCRIBED. THIS A I WRH BAN <br /> JOAOUIN COUNTY DEVELOP/MENTI TRLE,CHAPTER 9-111O.J ANO THE$TANDAPDB OF BAN JOAOUIN C.OfUNTY PUBLIC HEALTH BERVICFB,ENVIRON ENTAL ALTH . <br /> JOB ADDRESS/OR AM 4::4>�F $ ' ��L� /�YnTw FCe crr � LOT SIZE <br /> OWNER'S NAME P�1'77 ADDRESS RHONE <br /> CONTRACTOR >ti_ _ /� ADDRESS 4/ kELfjjV ,. Zg3 _ LIC) (,k— PHONE�i�/-itZ7 <br /> SUBCONTRACTOR ADDRESS UC# PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION ❑ <br /> [NO SEPTIC SYSTEM PERMITTED IF MBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDINO.1 PL T"T(.I 1 1 HOW MANY <br /> APPllosaon B <br /> F <br /> INSTALLATION WILL SERVE: RESIDENCE 09- COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF UVINO UNIT*:Z NUMBER OF SEDROOM*: NUMSEII OF SMKOY'EE*: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP BOIL CHARACTER: WATER TABLE DEPTH r <br /> SEPTIC TANKIOIEASE TRAP ❑TYFEWFG CAPACITY NO.COMPARTMENTS <br /> PKO TREATMENT PLANT❑ DISTANCE TO NFARUT: WELL FOUNDATION PROPERTY LINE 1 <br /> t <br /> UFT*TATON❑II�-S�1IZF TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> UEACHWO UNE Ea NO.B LENGTH OF LINES j-1/0 / DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIDTH UENGTM DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED C❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE PIT* Q DEPTH SIZE Z( NUMBER_L_DISTANCE TO NEAREST:WELL FOUNDATION %j A"O PROPERTY UNE 4C'CI ,C <br /> SUM" ❑WIDTH LENGTH OEPTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH UENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULE; <br /> AND REGULATION$OF THE BAN JOAQUIN COUNTY.ROME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT 16 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 <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN-8 COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOUIIS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. CONIKETE DRAWING BELOW. <br /> SIGNED 42z TITLE: 1DATE: <br /> PLOT PLAN(DRAW TO SCALE)SCALE 'I. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY fT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIXB. THE PROPERTY OR ADJOINING PROPERTY. <br /> j <br /> NOV <br /> II <br /> 1 b4 E <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE' J ///��'��, AREA: 7- 1 <br /> TANK, q BUMP INSPECTION BY DATE&��LJ FINAL INSPECTION BV / DATE <br /> 1 <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AID/ FAC# <br /> PE CODE FEE INFO AMOUNT REMIT ED CHECK ICAEH RECEIVED BY DATE M/PERMIT NUMBER INVOICE# <br /> 1/ <br />