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APPLICATION FOR LIQUID WASTE PERMIT SAW JOAQUIN COUNTY PUBLIC HEALTH SERVICES Oc" l �� ENVIRONMENTAL HEALTH DIVISION l 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 I NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I I n �/;/ (CBmpIBto In Triplkebl V Cl. APPLICATION 16 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS AFPICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT Trt .CHAPRER B,E1/1)1/0.3 AN/D/-THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEEEMCES,ENURONMEMAL HEALTH DIMBION, JOB ADDRE6B/ORAPPN/(� _ / / 1✓ '� ��/'J�,.,, �� CITY �1��L- LOT SIZE_ OWNER'S NAME I �TILf"� LaJ� �I`� C- ADDRESS I' /7/✓u� �� /' RHONE �II (� CONTRACTOR / RiJ�[Y] FYI ADDRESS /2�'( F• G�E.C'I�•-YI �l -A' C��UCF Y 2S- RHONE t( DC/-FL"�� / SUB CONTRACTOn ADOK I)CF PHONE TYPE OF SEPTIC WORN: NEW INSTALLATION ❑ REPIUmADp110N DESTRUCTION ❑ IMO SEPTIC SYSTEM PERMITTED IF RIBUC 6EYJER IS AVMUBLF WITHIN PEIC TOTEM I 1 NOW111AMAY 41 INSTALLATION WILL SERVE: RESIDENCE I[l COMMERCIAL ❑ OTHER ❑ NUMBER OF IMNO UMTS: / NUMBEIR�O//F BEDROOMS: NUMBER OF EMPLOYEES: CH TER OF SOIL TO A DEPTH OF 3 FEET:{}�/iyr:te_ RT/6VMP 601E<HARACTERu/a ` LYATER TABLE DEPTN ilt NNOIEASE TRAP ❑TYFE/MF% t1V, C C4-1I✓ CAPACITY Ly LFA NO.COMPARTMENTS W(0 FREATMENT RANT❑ DISTANCE TO NEAREST: •WELL C7 '� FOUNDATION ti PROPERTY LINE IRIIf II-AI(11 QF(31/�A. i LIFT STATION❑ SIZE TYPE OF PIMP //� SAND OIL SEPARATOR IENCLO6ED SYSTEM) I��I�NQNIAI'N IFl :I 6111:I'i��l`^ "' LEACHING LINE ��PGT,CS LENGTH OF LINES —41ZP -'I-Q- DISTANCE TO NEAREST:WELL �lC ''�FJJ��OUNDAiroN /0 ' PgFERFV ZINE J FILTER BED U WIDTH LENGTH DEPTH DISEANCE TO NEAREST:WELL FOUNDATION PROPERTY ME MOUNDED ��❑yyWIDTH ^f LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS PTN r S/ BEE _NUMBER I INSTANCE TO NEAREST:WE EK I FOUNDATION le J PEOPERTY UNIT SUMPS ❑WIDTH LENGTH DEPEH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE MIN BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR UCENSFD AGENT'S SIGNATURE CERTIFIED THE FOLLOWING:'I CERTIFY THAT'NINE PERFORMANCE OF THE WORK FOR VMICII THIS PERMIT IS ISSUED.I SHALL HOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME BUWECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIFI OR SUB CONTRACTING SIGNATURE CERTIFIED THE FOLLOMNO: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CONIFERS LAWSOF CALIFORNIA' THEA AMT MUST CALL 31 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPLETE DRAWING BELOW. J� SIGNED X /1 TITLE:��L/ DATE: Z ROT RAN DRAW TO SCALER SCALE_ •to \j.� I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DI6EOBAL SYSTEM OR WROPOSED •••VVV111R\\\w��l Z. OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANBpN OF BEWAOE DISPOSAL SVBTEMB. ( 1 1 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTYFT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,ORVFWAYS.AND WALKS. THE PROPERTY OR ADJOINING PEOPERTV. -e- 4. /�"p;<s 1 �U115 C UO ' 3„ � a TMMT USE ONLY FOR M APPLICATION ACCEPTED BY `•`• C'" ( DATE: ` I `' AREA: TANK PIT OR BUMP INSKCTIO14 BY1� ,pE DATE / / FINAL INSPECTION BY � O DATE TIONAL COMMENTS: �zv�R L� ,•L% C\ aa-Almv, 1 LV..Y•�iTC2`^ "YC.E-Q�VL� -y > "R " ! — dv ✓�-,-, ( FnA 1 L ACCOUNTING ONLY: A. FACS PE CODE FEE INFO AMOUNT REMUTEO CIIECNF/CASH RECEIVED BY DATE M/PERMIT NUMBER INVOICE/ Pub,He611h Se, -Enviro. 174(3/96)