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APPLICATION FOR LIQUID WASTE PERMIT S._ . JOAQUIN COUNTY PUBLIC HEALTH ,_ AVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 11011•REFUIIDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFFER 9-1110.3 AND THE STANDARDS OF S�Ns JOAOUINI?C��O NTY PUBLIC HEALTH SSEEER1V�ICES,E NMENTAL HEALTH DIVISION. /1 e.,, JOB ADDRESBIOR AAPN' / S 0 ✓`� - �O-/1(�- -1 `�- CITY ((X/� LOT 812E�i��' OWNER'S NAME, 'DCCe "��- ADDRESS 1�,-^0 l• �1I��' � cPHONE CONTRACTOR Z� ( LIC' (ZL - PHONEy` -3' z 1 < { 2'I ChW SUB CONTRACTOR ADDRESS LIC' PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PFPC TESTI.)( 1 HOW MANY Appeoatlon! INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ Z OTHER 11NUMBER OF LIVING UMTS:_ NUMBER OF BEDROOM$: 3 NUMBER OF EMPLOYEES: �� EPTH CHARACTER OF SOIL TO A DEPTH O 3 FBF/ Sw PR/SUMP SOIL CHARACTER/74'/ OWATER TAB COMPARTMENTS C T NK/OREASE TRAP ?_Q)JL PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION• ' J PROPERTY UNE �d UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE INO.S LENOTH OF UNEB 3`�D' 6'^A-2- DISTANCE TO NEAREST:WELL FOUNDATION C D PROPERTY UNE /c9d FILTER BED /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH r� LENGTH DEPTH Z DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS EPTH5 SIZE NUMBER 3 DISTANCE TO NEAREST:WELL FOUNDATION ADO p110PERTv LINE /00- stomps ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE ---- I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AN THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REOULA OF THE JOA COUNTY.HOME OWNER LK:ENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM IS 18 ED,1 At. EMPL ANY PERSON IN A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CO RACTINO A IES T FOLLOWINO:'I RTI THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORCM N'S COM T C A.' TH UST CALL 24 HOURS IN ADVANCE FOR ALLLL E�OUIR INSPECTION$. COMPLETE DRAWING/BELOW. SIGNED TRUE: `(J V�-'1 • DATE: l O- 7- �" N PLOT PLAN(DRAW TO SCALE)SCALE_ to I. NAMES OF STREETS OR ROADS NEAR O 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 -.. .. - .. ...:... :.._ .... .......... ........... .. .... .... ._. .. t(Q e .. . --bA�� ...... .. ,. .. \ .. ......... /I .. _ . ........ .. ..... .. ......:... ` .. .. ........ .: Nocs� ... '..... ...... p<.... .ta.'.'...�.�'. . .............. .. .. o r ��... .... .. ..:....OCT7 _ .. .. . :.......... ..:.. .. lol ;tom ' �uausaa r�i. �,,J►�rr.. .... •v ll • /Lb .... r N✓iF{Ots1A?EiyTAF►Jt;4ttti IlslYl3. .... _.. . . ........... ..........`