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APPLICATION FOR LIQUID WASTE PERMIT ffN JOAQUIN COUNTY PUBLIC HEALTH SERVICES- ENVIRONMENTAL ERVICESENVIRONMENTAL HEALTH DIVISION RO, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicat,l APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.(CHAPTER 9.1110•.3/AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIPONMENTAL HEALTH DIVISION. / JOB ADDRESS/Oft PP'NI �/ �� /I// /1/K�-t�'j�/T./ Gf CT' 1Jn/�f(fs / �J LOT 81�E OWNER'S NAME -AK"Ll"2 C C�JT/.�-I ADDRESS f e 'J ✓X �CZL CONTRACTOR ADDRESS LIC# PRONE SUB CONTRACTOR ADDRESS LIC# RLONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION RIO SEI'TIC SYSTEM PERMITTED IF PUBLIC FEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING I P01C TESTIO I I HOW MANY APPIbABon F INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUM8ER OF BEDROOMS: NUMBER OF EMROYETJ: SHARACTER OF SOIL TO A DEPTH OF J FEET: PTISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPEIMFp CAPACT- NO.COMPARTMENTS TWO TREATMENT RANT El DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED B VEM1 L EACH NO ONE ❑ NO.B UNOT14 OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED ❑WROTH LENGTH DEPTH DISTANCE TO NEARERT:WELL FOUNDATION PROPERTY,LINE MOUNDED ❑MDT14 LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PTS ❑ DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I a SUMAS 11 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE p� DISPOSAL FONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PIOPERry LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULER AND REGULATIONS OF THE BAN JOAOUIN COUNTY.HOME OWNER OR LICENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR `1 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS 8 U8JECT TO WORKMAN'S COMPENSATION LAWS OFF CCALIFT,OMIIA.'/TTHH"EE APFUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INBPEOTIONS. COMPETE GRAMM BELOW. Y SIGNED TRY LF: DATE: PLOT PLAN(DRAW TO SCALE)SCALE IS 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DI6POBAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ]. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY ET.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. S TAAI EJ N�vsz' c� i v � N Z 6 i II n v ^ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �yyr va» DATE: A. 5 TANK,PT OR SUMP INSPECTION BY DATE I I FINAL B/MECTION By ATE---A) / ADDITIONAL COMMENTS- ACCOUNTING ACCOUNTING ONLY: AID# FAC# IE CODE FEE INFO AMOUNT REMITTED CNECKI ASH RECEIVED BY DATE M I PERMIT NUMBER INVOICE# 4 Z Z 5a q / 4 p�a� 1/