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?PLICATION FOR LIQUID V.ASTE PERMIT .� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT PIKES i YEAR FROM DATE ISSUED IComphrtB In Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTHySERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESB/OR APNO� —L10 4 c3 S p p ✓+ ICT CITY ( �1LN 7'E C,� �� LOT 812E OWNER'S NAME 1J O N lJ 1..1 F S ADDRESS -Z y AtS �.1 S" 1 (� t 1-1 PLC-^ (�4 PHONE CONTRACTOR ADDRESS UC, PHONE SUB CONTRACTOR ADDRESS LIC, PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) ,.{7 �� / PERK TESTI.)I 1 HOW MANY IApp0m0on, INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL 0' OTHER ❑ �.I I NUMBER OF WINO UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: U / CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TAB DEPTH SEPTIC TANK/OREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS VVVV��v��, S I n- `_\ PKO TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ��Y/1 13 UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.6 LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW(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 CERTIFY THAT IN THE PERFORMANCE OF THE WOFS(FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOW(MAN'8 COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOLWS IN ADVANCE FOR ALL REQUIRED INwSPEECCTION$. COMPLETE DRAWING BELOW. SIGNED Xy TITLE: ( /C '✓G� DATE:�j- PLOT PLAN(DRAW TO SCALE)SCALE -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. _. _.... ..!.. :... ... ... ._ ... .. ..i .. ... ._ ...... �. ...._ /._. ... _. . .. .. .....0.... _.. _:.. .... .:.... ..:_... .::. .. ?.. .. .. ... ___... ..... ..... .: ...:. ........ ....;... >__ ..... ....... __ . .i .. _ y IL'I 0/EtJ �-° RECEI .... ... ... . . . NOv 2 4 X999 ... ary�oAoww c'Cri'< ---� Pu8u.^N Eerrv+Rorrn�� r, , /OK FOR DEPARTMENT USE ONLY / �. APPLICATION ACCEPTED BY DATE:f/// e: AREA: TANK,PIT OR SUMP INSPECTION BY 0 1Z DATE / / FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: AD, FAC, PE CODE FEE INFO AMOUNT REMIITED CII CK, ASH RECEIVED BY DATE BR/PERNBT NUMBER INVOICE, Pub.Health Serv.-Enviro.174(3/96)