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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SEFr:IICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICBmplatB In TripliaatBl APPLICATION 18 HEREBY MADE TO THE BAN JOADIIIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE VMEH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1110.3 AND THE"AWARDS OFSAM"AMIN COUNTY MOM HEALTH INERVICES.ENVIRONMENTAL HEALTH DIVISION. // JOB ADDRE6810R ATARI .� / / CT' iTl� LOT NEST 'T.. - OWNER'8 NAME ADDRESS HONE CONTRACTOR ADDRESS a N PHONE SUBCONTRACTOR ADDRESS " MO PHONE TYPE OF SEPTIC WORN: NEW INSTALLATIOIyZr REPAIRADUITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WTTHIN 200 FEET OF BUILDING.) MAC TESTIS(1 1 HOW MANY 1).- APPYstlFIR I INFTALLATION WILL SERVE: RESIDENCE 11 COMMERCIAL El OTHER 0 ! r t --,� NUMBER OF WING UMTS:_ NUMBER OF SEDROOMS: NUMBER OF EAROYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PTISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS WO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL - MUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM( LEACHING UNE ❑ NO.E LENGTH OF LINES 4/!`�'y� DISTANCE TO NEAREST:WELLFOUNDATION POPERTY UNE FILTER BED ❑WIDTH LENOTN DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNOATION PROPERTY UNE BEVAUE INTO ❑DEPTH _ SITE NUMBER DISTANCE TO NEAREST:WELL /fG . FOUNDATION PRDPENTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL MUNDATION PROPEFTY UNE DISPOSAL FONDS ❑WIOTH LENGTH DEPTH DIBEANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE BAN"AMIN COUNTY.HOME OWNER ORLICENSED AOENE'S SIGNATURE CERTIFIES THE MLJ OMNO:'I CERTIF/THAT INTHE PERFORMANCE OF THE WORK FOR WHICH TNR PEIKGT IS ISSUED.I MAU NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S NNW OR SUB-COFEERACTING SIGNATURE CEFGIFIEB THE FOLLOWING:-1 CERTUNIITHAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18188UED.1 SIIALL EMPLOY PERSONS SUBJECT TO WOFRMAN'8 COMPENSATION tAWB OF CAUPoIWIA' THE APPIICME�Rf�n`,mT CALL K HOURS IN ADVANCE FOR ALL REMORED INSI ECTIONS. COMPLETE DRAWINO BELOW. J \ SIGNED X_ �1 )L J J ' TITLE: DATE PLOT RUN(DRAW TO SCALEI SCALE •I'- 1. NAMES OF STREETS OR MADS NEAREST TO OR BOUNDING THE PROPIPAW. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE OISMSAL SYSTEMS. 3. DIMENSIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROMISED STRUCTURES, S. LOCATION OF WELLS WITHIN MINUS OF ONE HUNDRED FIFTY FE.ON INCLUDINO COVERED MEAS SUCH AS PATIOS,DRVEWAYB.AND WALPK6. THE PROPERTY OR ADJOINING PROPERTY. tNty 9 HLI TH e•EFIVIGE� \ poBUC d,RONMEFITAi HEALTH O1Vl910N__. _ _ . .._ 14 FT I A L _ �_� FOR DEPARTMENT USE ONLY yyN APMCATION ACCEPTED BY '/ /llsY jL DATE: AREA' LJ TAHKOR BUMP INSPECTION BY DATE I I FINAL INSPECTION AO'NTIONAL COMMENTS: ACCOUNTING ONLY: MIO/ FACT %CODE FMIRFO wOUNTMMIITEDIEC KABH RFCEVED BY DATE W/PE VAT NUMBER INVOICE/ Lf,��11II C�hItV qq �o/��.v KS=K/ar of?Gvni5.=R7 'rn� r^T5 lir-,wwv.'-ZIF�oA$1K( Pub.Health SOrv.-EnvirD. 174(3/96) I ,Cyt-rnry K5"o J '3o,C C�r.l-I floc,Tge w I 9�3I9R: =e�� 1 Ga .:GTrPn /' L r /FA,- SYS E� Vr- T�IJd/�o oKc'� ✓�' TD L/,=T SSR-rOAI t3`C 9/�ySo�.,e/��J 9/S.7t=j V�IE�F.,s�