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APPLICATION FOR LIQUID WASTE PERMIT S� c :N JOAQUIN COUNTY PUBLIC HEALTH v. RVICES G3 � ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 MON. I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `{e (Complete In Tripliests) APPLICATION IS HEREBY MADE TO THE SAN JO PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAOVIN COUNTY DEVELOPME RLE.CH 8- !!3� NE T ARDS OF BAN JOAQUIN COUNTY PUBUC HEALTH BER ES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE SS/OR Af'NI �y I v yr u yC�ITY ,�7 V l.- LOT SIZE Lek OWNER'S NAME f`` E f Lv 1. ll 1 VIRE S `�� 1�f nn+l 1 WLl-/ i-JF t• PNONE/ CONTRACTOR K�il' �- ADDRESS uc/ Y� PHONE SUB CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAMADDITION ❑ DESTRUCTION ING SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI)1 1 HOW MANY Apptle�tlen/ INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UMTS: NUMBER OF BEDROOM!: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/MFASE TRAP ❑TYPE/MFO CAPACFTY NO.COMPARTMENTS PCO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOVNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH SIZE NUMBER INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE Y HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S MONATURE CERTIFIER THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED 4 ISD TITLE: CTLtA�tL/� DATE: L—� f :� PLOT PIAN(DRAW TO SCALEI SCALE 'w 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OVTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION 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 WALK$. THE PROPERTY OR ADJOINING PROPERTY. . p .. .J.. ... .. - _. _.. . _....... ..... .. ..!.......;.. .__ ...... i.. _.._ _.__ _. :...... ....i. _. :_. .'... .. ... ....... '. _:.. .... �1 _. .:. .. mr :. _. ..... ................... .......... ... .......... ,.....:., 1i.-J ...... .. . :. ANS . _ " .D :.�. ... C.C�UNT � SI�E+airn�.ttnt 1'uu c rF Y _. U H �LTN �FIaVIDES _. _ _ .. ... RONMENTAL HF_,11.fH DMS FOR EDM USE ONLY �� APPLICATION ACCEPTED BY v, C�"`��-•�� DATE: �O- 1 L AREA: TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY!�'Iu LZ j�Y1�i f"l'Lv. 1J'ATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: ND/ FAC/ PECO^DE FEE INFO` AMOUNT RDA ITED IIECK/ BH RECEIVED BY DATE OR/PERMIT N INVOICE/ Pub.Health Serv.-Enviro.174(3/96) ` +0 �P