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i0o0 APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. TH19 APPLICATION 19 MADE IN COMPLIANCE WITH BAN JOAOUI^I COUNTY DEVELOPMENT TITLE, �C1/HAPTE`/R--'�9-1110.3 AGO THE ST NDf AMB 7O�itF,I"(7 , AN JOAOUIN COUNTY PUBLIC HEALTH SERVIC�E/S..ENVIRONMENTAL HEALTH DIVISION. 2o l M (< lX c �� TY C.� LOT SIZE JOB Ao0r1E9s on nrN# c1ry r, � CT 1;I �d ADDRESS PHONE OWNER'II NAME ` FFF-��c CONTRACTOR ADDRESS LIG# PHONE SUB CONTRACTOR ADDRESS LIC# PI IONF TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPALWADDITION ❑ DESTRUCTION ❑ IND SEF-TIC SYSTEM PF"ITTED IF PUBLIC 6R IS AVAIL A LE WITHIN 200-FQET OF BUILDING.) PERC TESTW 1 1 HOW MANY fit.ti--Z -�-1 le, j IY�T` � APPBoadon. INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ 11✓ NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMP.OYIE:S: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH- SEC TANK/OREASE TRAP ❑TYPE/MFG CAPACrrY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE L'FT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEMI LEACMNO UNE ❑ NO.6 LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH D19TANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE HTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WOFK 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 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 COMPEN ION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 UFLS IN ADVANCE FOR ALL REQUIRED INSPECTIONS- COMPLETE DRAWING BELOW. /�/�1 ` _� TITLE: v / / ( I.:� DATE: . SIGNED X `^ ' `�-�� / PLOT PLAN(DRAW TO SCALE)SCALE_ 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. FXPANSiON OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. 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. .. .. .!. _..... ..... a N,Y IYi1 4`i V __.- _ %, p nW X)AOUIN CWI.. pUgUCHEALTH SERVICES _ ..: ENVIi or4MEWAL 9CAI_(H iWrSIM � n OR DEPAPTM ENT USE ONLY C/ APPLICATION ACCEPTED BY � 1�1 J L' 1 `A.'C^� DATE: t� AREA: TANK,ME OR SUMP INSPECTION BY DATE / / FINAL INSPECT1ONN BY ADMIGNAL COMMENTS: ACCOUNTING ONLY; AID# FAC# PE CODE FEE INFO AMOUNT REMI ITED CIIEC /CASH FIECErVED BY DATE SR/Pff"T NUMBER INVOICE f Pub.Health Serv.-EnvirO.174 3/96 ctol��