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APPLICATION FOR LIQUID WASTE PERMIT SA, JOAQUIN COUNTY PUBLIC HEALTH S-_,-VICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompbte In T►Ipiieot@I APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT 10 CONSTRUCT AND/On INSTALL THE WORK DESCRIBED. T1119 APPLICATION 18 MADE IN COMPLIANCE WITt1 N/ JOAGUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110,7 AND�/�J�1E STANDARDS OF BAN JOAOI/It1 COUNTY PUBLIC HEALT /BEnv110EB,ENVIRONMENTALL/;HEALTH DIVISION. JOB ADDILE8810 I I" ((�/ CITY4LTrl�1L't r�� "��. U LO T[817E} OWNER'S NAME-rAO- N ADDRESS -/ /`/l/� L -T L-T1 t� •f��l PHONE-�7Y-�IC�C' CONTRACTOR ADORERS III--- LICIF PHONE SUB CONTRACTOR ADDRESS UCS PHONF TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRMDOITION ❑ DFSTRUCTTONTu INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING., /\ PERC TESTI.)1 I HOW MANY Appsaetlen f INSTALLATION WILL SFRVE: RESIDENCE 161,�(/ COMMERCIAL ❑ OTHER ❑ MLA48E1 OF LMNO UMTS:_ NUM///RIE OF BEDROOM,: _ NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/BUMP BOIL CHARACTER: ATER TABLE DEPTH SEPTIC TANK/ORFASE TRAP PYTYPEUMFG L7 r CAPACITY NO.COMPARTMENTS PKO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ 617E TYPE OF PUMP—(�/—�-BAND OIL SEPARATOR IENCLOSED SYSTEM, Me LFAC{SNO UNE ❑ No.a LENGTH OF UNEB 1.) /-/J DISTANCE TO NEAREST:WELL, CZ / FOUNDATION Af PROPERTY UNE _ FILTER BED ❑WIDTH LENGTH DEPTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTHDISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE NTS ❑DEPTH SIZE_NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE —�-- SUMPS ❑WIDTH LENOTH DEPTH018TANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE — I HERERV CERTIFY THAT 1 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 JOAOUIN COUNTY.HOME OWNER ORLICENBED AGENT'S WONATVRE CERTIFIER THE FOLLOWING:-I CERTIFY TNAT IN THE PERFORMANCE OF THE WORK FOR WHICH TIB@ PERMIT 1810"0.1 SHAL NOT EMPLOY ANY PERSON IN SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S CO MPENBATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRNO OR SUR-CONTRACTING SIGNATURE CERTIFIES UA FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY RTRSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OFC INE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RIGURED INSPECTIONS. COMPLETE DRAWING BELOW. eIONE TrTL.E: PLG•• DATE PLOT PLAN(DRAW TO SCALEI SCALE_ 't- MES 1. NAMES OF STREETS OR ROADS NEAREST T BOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL 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, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED ARREAR SUCH A8 PATIOS,ORVEWAYS,AND WALKS THE PROPERTY OR ADJOINING PROPERTY. 3 A MAR 51999 A 'JQ Ir C• - �NVI pIJMi;TII 1 1 .�l.0 l 1 1V!'�".. GX 1 STI+,j (i W� FOR DEPAPTMENT Usti CNI Y DATE. AREA: A ATION ACCEPTED By I ///l� IL i�� •-''Z� �L A `'' / it C A'rJ� ^-PFCTION BY ' ��D TE �ANJC IdT OR BUMP MBR`ECDATE A1 iNzz TIOH By c` --r'-•---�/' AODIi zlz GARMENT 8: . ACCOUNTING ONLY: AIDS FACS C / ��_ �"'/ PFCOOS FET INTO AMOUNT RFMIITED HFCKS SH RFC EVFD 8Y _DATE - - M I►fTp1AT NI/ASR ER INVOICE f Pub.Health Sery -EGviro. 174(3/96)