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)APPLICATION FOR LIQUID WASTE PERMIT SAo,.'JOAQUIN COUNTY PUBLIC HEALTH SLj,410ES -41 ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 '' (209)468-3420p I DC'; NON-REFUNDABLE PERM) EXPIRES I YEAR FROM DATE ISSUED REOP „- 16mpAta 1n Tr*lkatel APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED, THIS APPLICATION t8 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH 9 E8.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN/ + �O CITY _C� _ LOT 812E OWNER'S NAME ADDRESS t1 f - PHONE e� COFfIiACTOR ADDRESS z ' ` / O LK:/ � �Z IMONE 2a. SUS CONTRACTOR�„ �I�1�. •_ADDRESS UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLAYIOII ❑ REPAIWADDITION ❑ DUTRUCTRM- (NO SEPTIC SYSTEM PERMITTED 1F PUBLIC SEWER IS AVAILABLE WITHIN ZOO FEET OF BUILDING.) PERO TEST4d L I IOW MANY AppNa�tloh# INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMSER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET:_ PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKICRIME TRAP 0 TYPE/MFO CAPACITY NO.COMPARTMENTS PKQ TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE - twr STATION© 61ZE TYPE OF PUMP SAND OIL SEPARATOR)ENCLOSED SYSTEM) LEACHING LINE ❑ NO.S.LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE i FILTER BW ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE HTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST.-WELL FOUNDATION PROPERTY LINE BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WEIJ. FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAW JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND 11EGULATONB OFTM BAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA.' CONTRACTOR'S HIRING OR SUBCONTRACTING ATURE CERTIFIES TH FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO ATION LAWS OF CAL) =APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: --- _DATE. OF t PLOT PLAN(DRAW TO SCALED SCALE 'to 1. NAMES OF S ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF PERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, U. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ..... ...,,.. - ....i.....5... .... ...,. ....i...-, .,.. .. ... � �;.... . ...,... .. .. _. .. - ..... ..-- .>.. �] '. � . ........ . .. .. . . . .. . . .. .. .......... :........ .... ..... ... .. .. .. :...... ;. .. ................... :..... .... ...............................>.., ........... ................ ;.. • .... - ... ... ....... .. ..... - .. .. .. _ M1 .. .. / f"'wtl 'S I'1 +Eo.q v Rel it�i� .. ...,. _ . ..,. .... : .. _ :. :. .. . ,. , APR 14 �9�9: ;.. : ... ..... .........; ...:..-. :... .... .. . q; Uri . � SAI.J :....... .�TlSll .. r FOR DEPARTMENT USE ONLY (p APPLICATION ACCEPTED BY DATE: �El` + A !' TANK,PIT OR SUMP INSPECTION BY DATE I I _FINAL INSPECTION BY DATE I 1 _ ADDITIONAL COMMENTS: ACCOUNTING ONLY: MD# FAC# ' PE CODE FEE INFO AMOUNT RI MTITt4D CHEC H REC v ATE SR I P9WBT NUMBER INVOICE# a Pub.Health Serv.-ETTYiro.174(3196) y