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T 1 { �� �i3 _ APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION j P.O. BOX M% 304 EAST WEBER AVENUE, STOCKTON, CA 955-2955-201-W820t8(209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in TTipruals) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 ANtr THE\STANDARDS OF SAN JOAOUiN COUNTY PUBLIC HEALTH SERVICEeS,,ENVIRONMENTAL HEALTH DIVISWN. 00 38 ADDRESSIOR APNN `-'' n=/C � CY_ �/A ok)7 t��r4 _ LOT SIZE e� 7 "If f! IT E;'WNER'S NAME •� 1 r f t-j ADDRESS l� �� "' ��--�!U�� IL1� PHONE 9 JJ 6 F ONTRACTOR [��L'C1 �' 7 ..'. .._ ADDRESS LIC/ PHONE US CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION, DESTRUCTION 10 SEPTIC SYSTEM PERMNTED IF PUBLIC SEWER IS AVAILABLE WITHIN ZOO FEET OF SUILDING.) FERC TEST(al I I HOW MANY Applloetlon ar INSTALLATION WILL SERVE: Si COMMERCIAL 11 OTHER❑ FIUMBER OF LIVING UNITS:_ NUMBER.F BEOROO R: NUMBER OF EMPLOYEES: HARACTER OF SOB.TO A DEPTH OF 3 FEkU) /'1rX_ r ISUMP60!4CHAR�CTER: WATER 7A�LFDEPTH `f-� SEPTC TANKMIRFASE TRAP 6a ;2 "4( ]—C,QQinftL , 6, �,71,I(OCOMPARTMEN TS �^ O TREATMENT PLANT C3 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE f l a 'tCS� LIFT 6TATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) -LEACHING UNE 91 NO,A LENGTH OF UNES�/l �' T DISTANCE TO NEAREST:WELL r FOUNDATION �4 PROPERTY LME FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE [EEIPAGE OUNDED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH - LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE .HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICAMN AND THAT THE WORK WELL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULE` AND REGULATIONS OF THE SAN JOAQULH COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:`I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHOC HWS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANV PER36N IN SUCH A MANNER AS TO BECOME SUBJECT 76 WQRKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING O UB-CONTRACTING SIGNATURE CERTIFIES TH£FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO /ORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWINO�yBE.L�OW..� ^�J SfGNED X TITLE: DATE: J 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 018MOAL SYSTEMS, DIMEN610NED OUTUNInS AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTVRES, S. LOCATION OF WELL8 WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLU O COVERED ALAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, THE PROPERTY OR ADJOINING PROPERTY. ., ....., .. ........ - --i- ...-..., ..: .:. . . . ..> . ...: .. .. a .. .. .. .. }.. o , r .. . ... ... .. � ...tj� zr Z ;.. ? <. ... t /. �.. SEP 2.... -. . .. ...... .5:1997. - - - Pu a _ �ENVi�tktAL7 ory SFAvrcn �V Ff f �- � hL_N