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APPLICATION FOR LIQUID WASTE PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH`:,,,-'RVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED COPY (CemplBtB In TripBeata) FILE APPLICATION 18 HEREBY MADE 70 THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THF9 APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.C AFTER 19-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH(SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE86/OR APNI V ti{1y \�� Q�\ LOT SIZE OWNER'S NAME, (! �, p0 C AbDREGS C PHONE S� !�1q' CONTRACTOR T'\�l 1i�"� \�L)� _ADDRESS .�6. LIC/ PHONE��2 / SUS CONTRACTOR ma,�yA, ADORERS LIC/ PHONE f TYPE OF SEPTIC WORK: NEW INSTALLATION YY REPAIRIADDITION ❑ DESTRUCTION ❑ i IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING-] PERC TESTIA I 1 NOW MANY - AppNe�den l INSTALLATION WILL SERVE RESIDENCE❑ COMMERCIAL 19 OTHER❑ NUMBER OF LING UMTS: NUMSER OF BEDROOMS: NUMBER OF EMPLOYEES:�Z . CHARACTER OF SOIL TO A DEPTH OF 3 FEET: S c''N PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIORL"E TRAP ❑TYPEMIFO CAPACITY `O NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL IAO FOUNDATION �l PROPERTY UNE LIFT STATION❑�S{IZE TYPE OF PUMP SAND OIL SEPARATOR IE14CLOSEU SYSTEMf wf a� s LEAC14NO ZINE NO.S:LENGTH OF ONES _DISTANCE 70 NEAREST:WELL !5r FOUNDATION �o PROPERTY LINE ALTER BED 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST-WELL FOUNDATION PROPERTY UNE - MOUNDED ❑WIDTH LENGTH DEPTH DIBTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH BRE NUMBER DISTANCE TO NEAREBT-WELLFOUNDATION PROPERTY LINE SUMPS TH LENGTH V�!�-�' -- --DEPTH!DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL POS LJ WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION 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 BAN JOAQUIN COUNTY.HOME OWNER OR UCENBEO AOENi'8 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WO(K FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENBATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTINQ.SIGNATURE CERTIFIES THE FOLLOWING:'t CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OFC FORMA.' T APPLIcAmiUMLIST CALL 24 FOURS IN ADVANCE FOR ALL RECIURED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: O*J V 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 DISPOBAL 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 FQY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. �ar'C .... ...... : .. ... .. .. . .. .. .. : xx .y q p.. ... .... Q.a.�.. ... . .... :.. . l - :. :............... ...... ............. .. .. �... � ro . .: ... .:......:.... ` . :........ ..9.11 .. .. ....:. .... .... .. .. . .. . I :. . ... ' i . ... .�.: 8. ..: �A,:.il� Ca,ah i�IIJhI i Y.. ... fr'1'fiiL1" . ...:.....: ... ......:..... FW�fi�f~.. kf S�I�VECE5: 1+PFsS3hlCJiCN�'A�I..kIER,[.TH.dtVlSfpfN......: .... FOR DEPARTMENT USE ONLY__ti_ �;.,G�+;. .- APPLICATION ACCEPTED BY pyU DATE: AREA: TANK,PIT OR SUMP INSPECTION BY DATE l/21 FINAL INSPECTION BY a DATE ADDITIONAL COMMENTS: o�A —IgV ACCOUNTING ONLY: AID/ FACS SPE CODE FEE INTO AMOUNT RE MlCODE FEE INFO AMOUNT REMIITED NEC ASN RECEIVED BY DATE SR 1 PERMIT NUMBER INVOICE 0 Z. -y S 1b�gg i 'J Pub.Health Serv.-EnvirG.174(3198)