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APPLICATION FOR LIQUID WASTE PERMI' SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVH:.S w' ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 10 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 1 10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR A(�PNO /53 1 -t>. �H��LQ L ^ CITY �,.y�J T�G�J LOT SIZE E•LZe,'5 OWNER'S NAM/E�/� ""` KL �L�D 5m �! ADDRESS J� l �`I l-r��T�n� I �- PHONE Ed�J�� -�97== CONTRACTOR_t'`�-��I3�� 'A 5m FT ADDRESS ��5 i T`LT/K-4 1 IA L—` 6 UC11325a3 PHONE -1 ✓t��`Ll 1 SUBCONTRACTOR ADDRESS UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION j5t REPAIR/ADDITION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) P13RC TESTW 1 I HOW MANY APWl—don 0 INSTALLATION WILL SERVE: RESIDENCE QQ C1�OM��MERCIAL//J❑ OTHER ❑ p ,/ BER OF LIVING UNITS: F 5EDROOMS: ?I SER OF CHARACTER OF SOIL TO A DEPTH OF 3FEET: OWi'��NT�A.�IT/SUMP SOIL CHARACTER: �►`ND`( LoPrrwATER TABLE DEPTH 191r SEPTIC TANK/GREASE TRAP ®TYPE/MFG COW CR--rE! V74. L CAPACITY %.ZOO of a II O t-1) NO.COMPARTMENTS Z PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION T 3j4 I PROPERTY LINE �� ! UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE 9 NO.At LENGTH OF LINES 3 ' ' DISTANCE TO NEAREST:WELL FOUNDATION� PROPERTY UNE 50 , FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED �❑19 WIDTH LENGTH'1/I"� DEPTH DISTANCE TO NEAREST:WELL- FOUNDATION PROPERTY LINE DEPTH /SIZE R)'� NUMBER '� DISTANCE TO NEAREST:WELL 1 501 FOUNDATION O Z PROPERTY LINE /00 SUMPS 11WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE rU I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES vl AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH "'• THIS PERMIT 18 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 SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO V WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED-I�NSP-ECTION$. COMPLETE DRAWING BELLOW. Q SIGNED X r r4,�' TITLE: �'•'��I�L L� I DATE: 0 PLOT PLAN(DRAW TO SCALE)SCALE- 1. CALE1. 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. a �. ;.o .... o !� .. ............ '......... ..... . . ...... .k. ... ; Ny . .. JUL ,3 1998 <.. ............. AN. v NAI ENVIRENT4 NFSERkI( H ... .. :. ..... .......... ...)........ t .ALT}{ ...... . :.... . . .: Moet- : .�.. ... ... . 53� `�, IZELU 3 /A• FOR DEPARTMENT USE ONLY y� APPLICATION ACCEPTED BY ` DATE: REA: '2 I+[JPF/DI TANK,PIT OR SUMP INSPECTION BV DATE / / FINAL INSPECTION BV DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED C /CASH RECEIVED BY DATE SA I PERMIT NUMBER INVOICE 0 W