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APPLICATION FOR LIQUID WASTE PERMIT y��n S.. .J JOAQUIN COUNTY PUBLIC HEALTH RVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 SEPTIC NON-REFUNDABLE PERMIT EXPIRES I 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 SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPT,E,R/99--11'10.3 AND/THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH�SERVICES.ENVIRONMENTAL HEALTH DIVISION. ry JOB ADDRESB/OR APN/ / /J f tL� j /y`- �//)�/_1TI� / CITY /��,/9 ��-- LOT 812E OWNER'S NAME 11,411 /V4 ji 11"4 / A1111J.b �.rTTYy777 ADDRESS -i�� y,/� �,A�/�'SCII1 i/��` ��y.'r�LI PHONE G�� O��✓/� CONTRACTOR 11 /!i r/�L-L-G[�' ` ADDRESS j!Q 7 / a.� gC1TY �J / IeIJ/ __LICA�..��c� PHONE J. /% SUIT CONTRACTOR ADDRESS UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AODITION DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) FERC TESTI.)1 I HOW MANY INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑T 2 NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS: 6~ NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP 501E CHARACTER: WATER TABLE DEPTH _-�f SEPTIC TANK/ORFASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS ;1 C 7 ✓ '1n/ PKG TREATMENT PLANT 11 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYBTEMI j'JY V LEAC19NO UNE ISI NO.6 LENGTH OF UNES -'2- 7!1 F T- DISTANCE TO NEAREST:WELLzi��UNDATION r�F PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH S12E NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE BUMPS ®WIDTH LENGTH_DEPTH DISTANCE TO NEAREST:WELL/i'v ��' rFOUNDATION rT PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION 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 SAN JOAQUINCOUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON N SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGMRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED)( � C �� TITLE—{�` DATE: i71 A PLOT FLAN(DRAW TO SCALEI SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 5. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. t ... .... _ _ oG ... R Q .. .... ..... r� .. _ .. .... .. . .. . n IP'>f'1 m NT. .... .. ... 1 . FES �99�. . r ..- s v�UH.! iH Q. G� PL1 LI' H. S ( S ENVIR-NMENT L!HEALTH Dtt/IStON r, 7 FOR DEPARTMENT USE ONLY --(o APPLICATION ACCEPTED BY ` �I �/�} AA V)U lir JT'�\ DATE: � AREA: G�` TANK,PIT OR SUMP INSPECTION BY9 / DATE ! / FINAL INSPECTION BY DATE 3 / 2 ADDITIONAL COMMENTS: ^/+` 4 1 oc"d O V E ` ? R'Pf'< T IV P�r7�E0 ACCOUNTING ONLY: AID, FACT PE CODE FEE INFO AMOUNT RUM ITED CHECK/ ASH RECEIVED BY DATE SA!PERMIT NUMBER INVOICE I 2s5 o `A -'7 5 Cq , ",)c l.6 Pub.Health Serv.-Enviro.174(3/96)