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_ APPLICATION FOR LIQUID WASTE PERMIT SAh JOAOUIN COUNTY PUBLIC HEALTH SERVICES G�. ro (17 O ! ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED SEPTIC (Complbt$ In Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FQR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. T1419 APPUCATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AN,D THE STANDARDS OF SANJ JO�AOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/On AFRI % 7 I (:�-(.�lr}�`-,�v G JL /(i1L1 CITY y 7-V 4— F-21-2 LOT SIZE SEFG1L /L*f/0 r-7 /c�l5N/� �+�•/��— lam' �71 OWNER'S NAM�/(¢Y�/T7%.:2/Ai✓ ,T AALI/LGRT ADDRESS PHONE `//0 Z-6 CONTRACTOR ADDRESS � �j �{ LNC) PHONE SUBCONTRACTOR IL.«s iN FlF�Drt/2 ADDRESS z-fD ZEj 'y ' 0 •��/y� rz-,G— UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAINADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW( I HOW MANY Appllwtlon/ INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ `r �//� Q NUMBER OF LAM5 NG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: 5-A CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPEJMFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYBTEMI LEACHING LINE ❑ NO.•LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH D19TANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PIT$ ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑MUTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I 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 SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S 84ONATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIN PERMIT 16 ISSUED,1 SHALL NOT EMPLOY ANY PER90N IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE 1F1E8 THE FOLLOW) O:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IBSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENBATTU W OF S F.RHIA.• HE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED x 21TITLE: &I � DATE: PLOT PLAN RAW 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..... _._.i....__... .. ...'_._ .. :.._'. . ... ... .... .._ ... _.. ........ ._ :.. ....... ._......... .. .. ......; 5171 PUN .... ...... ......... ecOn$€�iL--?997 `J 1 Received 13Y--J�— .. .... .... ........ ... .A ... ... .. .... .. .:. .... ,tr �I ",.r'd ',iI '.ry Nf.l ,�' I=„ ` '[,ter , w�v r',�Jra d'y Y;4)>'T�6:yv ... .. ........... M . w "i u s� r .... .. exlsn N6 CROs .4 .o .._ ...... .. 1>um ;y EN41PoN �Nr_AL7Hs8nvICESR � M1Al EALTH H I.oAAo�„uwl.a Kaamu+ DIV) ... ................. I' _. _ ... FOR DEP TRENT U69 ONLY APPLICATION ACCEPTED BY DATE: S Z3 AREA: / TAW,PIT OR SUMP INSPECTION BY �YDATE l I FINAL INSPECTION BY J (ti/� DATE (�l( l �zr, ADDITIONAL COMMENTS: ^� ACCOUNTINO ONLY: AID/ FACT 1(4 ►E CODE FEE INFO AMOUNT REMIIT CII ABH RECEWED a DATE $R/PERMIT NUMBER INVOICE 0 52 -7 Pub.Health Serv.-Enviro.174(3/96)