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4PPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND TILE/ /)STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVIMN. 2` JOB ADORESS/On APN/ t�7(C� �J 'yzo4a /« CITY ! LOT SIZE OWNER'S NAME �A'y .L7 oe / A �S 5 -- �! / ADDRESS �1 / 17c�� L�f-� PHONE 7 J � CONTRACTOR 4 L /—/L�C: �� ADDRESS /�� i / �CJ /� 2/Y iC(_//� LIC/! PNONE��r76��.-� / —T SUB CONTRACTOR ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTNI t 1 NOW MANY �,/ Appklmdon S INSTALLATION WILL SERVE: RESIDENCE 1'O COMMERCIAL ❑ OTHER ❑ NUMBER OF LANG UMTS: j _ NUMBER OF BEDROOM$:�z NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: — / PIT/SUMP SOIL CHARACTER: �A 2�Q f 41.��TABLE DEPTH SEPTIC TANK/GREASE TRAP 11TYPE/MFG 12 L 1 CAPAC— 14%l NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL^ /GIj 4 FOUNDATION -Q PROPERTY LINE�Q�� LFT STATION❑ SIZE TYPE OF PUMP c� SAND OIL SEPARATOR(ENCLOSED SYSTEM) //, _ LFACHINO UNE 9 NO.S LENGTH OF UNES� _`'D CJ� 7— DISTANCE TO NEAREST:WELL FOUNDATION `6/r PROPERTY UNE FILTER PED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE_NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE t/ _ SUPS DTH j LENGTH [Je)U ' DEPTH L2 DISTANCE TO NEAREST:WELL�_�FOUNDATION`if PROPERTY UNE MWI DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOFK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RVLEB l AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR UCENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOW MAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOIKMAN'8 COMPENSATION LAWS OF CAUFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$. COMPLETE DRAWING BELOW. �i G SIGNED X / f i f=— /t�'�r TITLE: �-. l'� �'• - DATE: v 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 C� EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. 9. 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 WAS. THE PROPERTY OR ADJOINING PROPERTY. LX a. .. ._. ... _.. A . ... . ..._ ... .. .. .... .. .. 4°� I Y lac b �otip� 7 I - .. { .'.. .. .......... / ily�JJy, / _�/ FOR.EPA. f/duaEpNLv APPLICATION ACCEPTED BY DATE: AREA:—��-- TANK,PIT OR BUMP INSPECTIO BY DATE / / FINAL INSPECTION BY DATE / / ADDITIO NAL COMMENTS: 0 1 � / ��'�� ACCOUNTINO ONLY: AID/ FAC) PEI-ODE FEE INFO AMOUNT REMITTED CHECKI/CASN RECENED BY DATE SR/POVWT NUMBER INVOICE 0 L1 / / 0• 777 Pub.Heafth Serv.-EnvirO.174(3/96)