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PPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SEFMCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATKTN 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDREBBroR APN/ '2 v o � //��r_f� L✓�� //� cITY ��/-t L�-', LOT SIZE OWNER'S NAME --/ /�' �c" ADDRESS PHONE CONTRACTOR�((j//� ;jam!/G K.��C ADDRESS UC# I,�C.�rQ PHONE Sy JS�-I.�3 I SUB CONTRACTOR // // ADDRESS UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ® REPAIRUADDITION ❑ DESTRUCTION ❑ ING SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)1 I HOW MANY INSTALLATION WILL SERVE: RESIDENCE t COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING LMITS: NUMBER OF BEDROOMS: `/ NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OFCC31 FEET: PIT/SUMP SOIL CHARACTER: �} WAT//ER TABLE DEPTH SEPTIC TANK/OREASE TRAP r l TYPEIMFO C•—>•-C%•C/G CAPACITY ` Oo a.! C4 l R:'-' NO.COMPARTMENTS Z PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP ^ SAND OIL SEPARATOR INCLOSED SYBTEMI LEACHING UNE ® NO.At LENGTH OF LINES ' �V I DISTANCE TO NEAREST:WELL FOUNDATION 'ZJ PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE BUMPS ❑WIDTH 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 SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FORNMICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIO LAWS OF CAUFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: L0 Aj f DATE: PLOT PLAN(DRAW 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. C _ .. ... ... ..... ...... . .......... �I .. ..... .... .................:.. .. .. _.... ... . :.. .:. . ... .. ...... , ....:. .. ..... .. .. .. ...;. .... .. ........... . R .. . A .... .. / �,................... -....._. .1 y l ......!. ......_ ......... ......i..... ... .. .. .. . - ......................... .. ..... . ......... ...... t y _ -Inc" ��lat S , --rte .... ; ` .. t ..... ... .. FQ-&(�p,lENT USE ONLY (/"/� APPLICATION ACCEPTED BY �i�X/ �f ut '( (�/ DATE: L� AREA: ANK T ,RN T OR SUMP INSPECTIOBY DATE-- / / FINAL INSPECTION BY DATE -7191 ADDITIONAL COMMENTS: Fo—To ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMIITED NMR NECKS ASH RECEIVED BY DATE SR/PEFAMT NUSE INVOICE ' G —iro.174(3/96)