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APPLICATION FOR LIOUIO WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH s=RVICES �� ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IB HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMR TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TELE.CHAPTER 9-1110.3 y+D THE STAND RDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.�VI(, '/ENVIRONMENTAL HEALTH OIVN00N. A'J( JOB ADORE68/Ofl AMI / L^ � /"Z/�� /,y1- CITY !! \1 -r LOT SIZE OWNER'S NAME ADORESS S/'/ PHONE—.E CONTRACTOR ADDRESS UCS PHONE SUBCONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIMADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF RIBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF SUILDINGJI FERC TESTI.)I 1 HOW MANY INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER NUMBER OF"NO UMTS:_ NUMBER OF BEDROOMS: NU MASER OF EMPLOYEES: 'Yr CHARACTER OF SOIL TO A DEPTH OF S FEET: PR/SUMP SOIL CHARACTER: WATER TABU DEPTH SEPTIC TANIUOIEASE TRAP ❑TY'PEJMFO CAPACITY NO.COMPARTMENTS PALO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF MMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST'WELLFOUNDATION PROPERTY THE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑MOTH LENGTH DEPTH DISTANCE TO MAMST:WELLFOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION RMPERTV UNE SUMP, ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PIgPERTY LINE DISPOSAL RINDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPEfl LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL M DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REOULATIONB OF THE SAN JOACUIN COUNTY.HOME OWNER OR LICENSED AGENT'S MGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE YVORK FOR WHICH THIS PERMIT IS ISSUED,1 WALL HOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA.- CONTRACTOR'S HIRINQ OR SUB CONTRACTING MONATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PER FMANCE OF THE WORK FOR WHICH THIS PER UT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO^MPENSATION LAWS OO///FCC��L///��IF,,,OMIA.' THE APPLICANT MUST CALL 36 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION,. COMPLETE DRAWING BELOW. TITLE' i W C—'r�- DATE: ROT PLAN DRAW TO SCALE)SCALE_ ^Io U^ 1. NAMES OF STMETS OR ROADS NEAREST TO OR BOUNDING TIME 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. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADUS OF ONE HUNDRED FIFTY FT.ON (� INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PTMOPERTY. \` 01"T 14 1998 1 /J I FOR DEPAPTMENT USE ONLY APPLICATION ACCEPTED BY l DATE: AREA: TAW.PIT OR SUMP ADDITIONAL COMMENiSEC�JBY L DATE I I FINAL INSPECTION BV 7 a�C DATE // / LL211 da ACCOUMDNO ONLY: ND/ FAC# CODE FEE INTO AMOUNT Who I TED ITEC /CAbH RECEIVED BY {DATE SR/PERMIT NUMBER INVOICES 0 C 20 Pub.Heefth Serv.-Enviro.174(3/96)