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APPLICATION FOR LIQUID WASTE PERMIT 3AN JOAQUIN COUNTY PUBLIC HEALTh >ERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED 2 SGL (Complete In Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION I8 MADE IN COMPLIANCE WITH SAG JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE ST DARDS OF SANG JOAQUIN COUNTY PUBLIC HEALTH SERVICES,,EENVIRONMENTAL HEALTH DIVISION. 2 JOB ADDRESS/OR API! Z � — T �s 1 "C'D VC m �/ v9OT SIZE M,� A CRIER'S NAME ` Q- ADDRESS✓ . GA D S Z PHONE /�� gj CONTRACTOR P•n !_ �'n1f ADDRESS 53 SS So ctrQPIG� LIC♦ S� 37�rHONE _LLL.� SUB CONTRACTOR ADDRESS UC! PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPA)MADDITION ❑ DESTRUCTION ❑ 3 INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PMC TESTI�I 1 1 HOW MANY APPro.ron s PA'G i - ILS r � INSTALLATION WILL SERVE: RESIDENCE X COMMERCIAL ❑ OTHER MIMA ❑ j-/'7 C v UMBER OF LNG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: I O r ✓ C HARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPrH SEPTIC TANK/GREASE TMP ❑TYPE/MFA CAPACITY NO.COMPARTMENTS ►KG TREATMENT PANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.B LENGTH OF UNES INSTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE ,,AFILTER BED ❑WIDTH LENGTH DER*rN DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERrY UNE SEEPAGE PITS, ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANO REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CEIITIFYTHAT INTHE PERFORMANCE OF THE WORK FORWHICH THIS PERMIT 10 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:9 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.' TH ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPPEEC.TIO/N$. COMPLEDRAWING ANG BELOW. SIGNED X TITLE: (2-f1((V L j./✓ DATE: �� or PAN(Dluw To SCALE)SCALE_ 'to L 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED C 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPOSAL SYSTEMS. 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON L INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXS. THE PROPERTY OR ADJOINING PROPERTY. PARCEL I r r PAo4CL"L. 3 1VDIN6 4/CR>`S . � CORRAL I ZAST.Z6'F ROAD / VT SIS 20,E—.�, .S TOKASE • SEPTIC PARCEL Z 2 A4M s O MLL slay Y ... ...............:................ .. 9 2003 00n ..... )pAO�IN SE �110Es. pu A1C HEP�TN POSH DWI . _ y'U*W t _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 7 DATE: -5-- Q- ✓ _ AREA: 2-1 T C MP INSPECTIOnN �/,B /�y-DATE /�%�-7 FINAL INSPECTION BY DATE � ADDITIONAL COMMENTS:f'Y�� fl��G'^ 'Y/�^! `t-2- 1�NO�Lr' 7E'' F"'/7/•� � Z' �SDIZY��:SZJ A/A 2CJ- 3 > ACCOUNTING ONLY: AID! FAC! ►E CODE FEE INFO AMOUNT REMI$TED CHEC /CASH RECEIVED BY DATE OR/PERMIT NUMBER INVOICE! z�Z '10 +3 13 Y S Q 3 3-10- a� Pub.Health Sery -Enviro.174(3/96)