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APPLICATION FOR LIQUID WASTE PERMIT sAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICE$ ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 952010388 (209) 4883420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complsts in Ttipliests) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLIOATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TIT E,CHAPTER 8-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE8,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNF �%�7-A-H S`A9 i CRY LOT OWNER'S NAMEfP = wTI\\L>Pra_ C�g .I d,�y.'L ADDRESS ""Nr Cl < G_ ��r 50 CONTRACTOR —�P ADDRES3�.�—QYI �Z',[an LIC/ �1 nA PHONE `��0—J )3V SUB CONTRACTOR ADDRESS UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WRHIN 300 FEET OF BUILDING.) PERC TESTIS)( I HOW MANY Icy Applloadon IF0 INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ NM.IBER OF LIVINO UNITS:_ NUMBER OF BEDROOMS: NUIORER OF WFLOYYEEJ: 3 CHARACTER OF SOIL TO A DEPTH OF 3 FEET:Cj Pry PR/SUMP SOIL CHARACTER::CCK WATER TABLE DEPTH /U SEPTIC TANKIGREASE TRAP ❑TYPE/MFG CAPACT' NO.COMPARTMENTS PKO TREATMENT PLANT O DISTANCE TO NEMMIT: WELL FOUNDATION PROPERTY IJNE UFT STATION Cl SIZE TYPE OF PUMP SMD OIL SEPARATOR(ENCLOSED SYSTEM) f LEACHING LINE EX NO.S LENGTH OF UNES () yy DISTANCE TO NEAREST:WELL FOUNDATION,= PROPERTY UNEP FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED [❑a WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL ��,� FOUNDATION C PROPERTY UNE SEEPAGE RTS E7 DEPTH_ SIZE— NUMBER _DISTANCE TO NEAREST:WELL_.=FOUNDATION 5J PROPERTY LINE -,� SUMPS ❑WIDTN LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION 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;'I CERFDFYTHAT IN THE PERFORMANCE OF THE WOW FORWHICH K THIS PERMR IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUSCONTRACTING SIG TURF CEFTIFIE THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PLRMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN T11N IAWb IF UFORNIA.' THE APPLICANT MUST CALL 24 HOULS IN ADVANCE FOR ALL rR1EGUNIED INSPE/C�TIONS. COMPLETE DRAWING BELOW. G C SIGNED% l /1 _{IIV—JJI, TITLE: ✓L^2� (/I DATE: PLOT PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, b. LOCATION OF WELLS WRHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. C PAYMEN JUL 10 1996 SAN JOAQUIN OO, vt PU"RUC HEALTH SE.RVtCES �I ,� �, ENVIRONMENTAL HEAL'H DIVIS101 II