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APPLICATION FOR LIQUID WASTE PERMIT SAZY'JOAQUIN COUNTY PUBLIC HEALTH Sm-mVICES ENVIRONMENTAL HEALTH DIVISION �C 304 EAST WEBER AVENUE, STOCKTON, CA 95202 SEPTIC (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED IC*mpl*t* In Triplicate) APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 10 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDTRESWOR APN/ l/ '� �� GI CITY 4 . gLOT 81ZE OWNER'S NAME 25 4,of 1"L�/7 L ' ADDRESS /,, Da-x "� PE NE ( /375 CONTRACTOR M onk v ADDRESS ( t Da- ` s` UCI NE SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: INSTALLATION ❑ REPAIPJADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)1 1 HOW MANY Appli—d..# An S INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF WINO UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF J FEET: PIT/BUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TMP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING UNE ❑ NO.•LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINF FILTER BED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 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 BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR W"ICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAW*OF CALIFORNIA.- CONTRACTOR'@ HIRING OR SUB-CONTRACTING MONATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN87N LAWS OF CALIFORNIA.' THE APPLICANT MUST ALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. �] SIGNED X TITLE: I L-- L--Yy C'1 DATE: PLOT PAN(DRAW TO SCALE)SCALE__ 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE 018POBAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WTTH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED MEAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. Sec_ /4-`�Ll d I�!LOL Sc�c t ..... f t ... Z d r� ........... ....... ..... .. .. ._ ... .. . . . _'. .. _.. ... RECEIVED �►' ia ' NOV .... 2 31 .. .... ......... ............... ,99 Q :.. . ... . ',.E:NVIAUf jWM�N AQUIN CC)WJ 1 Y HEALTH SEflVtGEti .. TALI HEAL7W 0N18(0N T- FOR OEPAR ENT USE ONLY V�Y APPLICATION ACCEPTED DV L DATE:� �v 1' AREA:.�/2 TANK,PIT OR BUMP INSPECTION BY DATE / / FINAL INSPECTION By�LL DATE / v ADDITIONAL COMMENTS:f 2 /Z�4�rG9 ACCOUNTING ONLY: AID/ FAC# PE CODE FEE INFO AMOUNT REMITTED CURE ABH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE# �Z 41 Pub.Health Serv.-Errviro.174(3/96) 0 aA01