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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NONREFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete In Tr4lieStE) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT 10 CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE. �CHAPTER 9.1 10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH/SERVICES.ENVIRONNMMENTAL HEALTH DIVISION. C_ JOB ADDRESS IO R APN' G �/ �� CITY l `�L �- C� /��'/Z LOT ADDRESS PHONE1" OWNER'S NAME CONTRACTOR L'�r � ADDRESS� C ` 'L' -/_ I'/t �� UCf -�ONE SUBCONTRACTOR ADDRESS LICI P10NE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/AO DI T ION DESTRUCTION 13IMO SEPTIC SYSTEM PERMITTED If PUBLIC 6EVJER 16 AVAILABLE WITHIN 200 FEET OF BUI NO.I PE1C TFtTHI 1 I HOW MANY APW0MI0n S INSTALLATION WILL SERVE: RSE fiIDENCCOMMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITS: / N SER OF BEDROOMS: 3LMBER OF EMPLOYEES: /� ' 1 CHARACTER OF SOIL TOA DEPTH OF 3 FLET. 0-�IT 6U P L CMARACTER�--� �'�/ WATER TABIE DEPTH SEPTIC TANKUOREASE TRAP ❑TYPE/A/To / CAPACITY NO.COMPARTMENTS PKO TREATMENT PUNT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE 1 LIFT STATION❑ 61ZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED BVSTEMI- DISTANCE TO NEAIlEBT:VJE1J=lL� � FOUNDATION C' LEACHING LINE A IENGTM OF LINES �j L. PROPERTY LINE r FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE amps ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DI6TANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES S AND REGULATIONS OF THE 8 IN COV .HOME OWNER ORLIOENSED AGE 8 SIGNATURE CERTIFIES THE FOLLOWING:'(CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH < THIS PERMIT ISIS .I BH L E EMROV PERSON 1N SUCH A MANNER AB BECOME BUD ECT TO WORKMAN'S COMPENSATION UWB OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-COMPACTING 81 NATU CE FIE$T LLO :'i CERTIFY THAT IN THE RMANCE OF THE WORK FOR WHICH TH18 fUAR 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPNS T WB F TH pPIICANT MUST CALL 4 IBIS IN ADVANCE FOR ALL REQUIRED INS TIONS. COMPLETE DRAWING BELOW. l`� �► SIGNED �r PLAN aN RAW TO SCALE(SCALETITLE: DATE: ` _ r 1.NAMES OF STREETS OR 110AD8 NEAREST TO OR BOUNDING THE PROPERTY. 104.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED /\ Z.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM$. 3RO . DIMENSIONED OUTUNEB AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6.LOCATION WELLS WITHIN RADNS OF ONE HUNDRED FIFTY FT.ON -� INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTTY. ....: ._... ..._.- .. �Jov -(- .. T I.^.' .. ..:. FOR DEYAPTMENT USE ONLY APPLICATION ACCEPTED By��' '/ DATE: O lJ AREA: TANK,RT OR SUMP INSPECTI�IO14 BY DATE / / FINAL INSPECTION BY DATE / I ADDITIONAL COMMENTS: C-t t/�-L7'16(-' ACCOUNTING ONLY: AID' FAC• PE CODE FEE INFO AMOUNT REMITTED CNECKI ICA6H RFCETVFD BY DATE 6R I PERMIT NUMBER INVOICE! L__ C Pub.Health Serv.-Enviro.174(3/96)