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If <br /> 3LICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202n <br /> (209) 468-3420 (c <br /> { ) D <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED v <br /> (Complete iR TTIPIkStll <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATKON IS MADE IN COMPUANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1110,..3 AND THE STANDARDS OF SAN JOAOVIN COUNTY PUBLIC HEALT`H/SERVICES,ENVIFIONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNI, 70oS L7 gOO/ I S /�D CITY V A 4 L�1 AV I l E ,L/O7 812E <br /> OWNER'S NAME{/A )�� �s'���z ADDRESS �j7�o0 �7'�•�c�o n 5 Py PHONE I-� ZZ <br /> CONTRACTOR l�f`!�' � '�+� '",'/ ADDRESS J O <'-Ox 37q4 LK%I PHONEO�bV" 14-03 <br /> SUB CONTRACTOR ADDRESS UCI PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIAD04TION ❑ DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEUC TESTI.)I 1 HOW MANY <br /> AppMe.tlen. /45- yPJ�-43 <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS <br /> PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING LINE ❑ NO.•LENGTH OF UNES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SUMPS ❑WIDTH LENGTH DEPTH— DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON N SUCH A MANNER AS TO BECOME SUBJECT TO WOW MAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> SUB-CONTRACTINGATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COM TION LAWS FORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR <br /> "AILL REG/URED INSPECTIONS. COMPLETE OMWINO/B`ELOW. <br /> BIOMED X 1L .r TITLES:y7P t'�/y _DATE: /r O I <br /> PLAN(DRAW TO SCALE)SCALE_N`,T / y 'to-1 CALF <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OVTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> ...... ..... ............. .. .. <br /> .... ..........:..............:............. ... ..... <br /> .... .. <br /> .'......................i........... ... .. .. <br /> .... .. ...... <br /> .:..........:.....i..... ...... .........:... <br /> ..i.....;_. <br /> _.,.. <br /> ............... <br /> ...:......:.......:......:.....................:...... .. .. .. .. .. .. .. .. .. .. .. .. <br /> ... ......i..... <br /> ..: <br /> :......:.......:.....:.......i..............i...... .. <br /> ..................... <... . (� <br /> ....:....... ... <br /> :...... ................ ..... .,. ................. .. ... ... .. .. .. ... <br /> .. .. <br /> 1 <br /> ........... <br /> ... ............... ..... .............. <br /> ........ . ..� .... >........................... .. .fs ` f <br /> ....<............. . Cb.... <br /> ........:............. <br /> : YSil�r► rF ?... ... �JZcG.....:��4RCEt... ......... <br /> ...... ................:...... <br /> P � G <br /> A(iv D�2 <br /> . <br /> ............:.....................:............... <br /> ............. . .......... ...........:........ <br /> jj O.x1=u, <br /> ........ .. <br /> ... . <br /> ..._. ... <br /> 1' <br /> ..... � <br /> ; . <br /> .............................. .. <br /> >. ... <br /> .. <br /> _...:....:.......:....:.......E......; - i .7F1fi J'JnQI LIN(,1)I.;NTY :.. <br /> J 1. <br /> .. .... <br /> �EtL HEALTH DIV191L)r+ <br /> FOR DEPAPTMENf USE ONLY +I CI <br /> DATE: ` � AREA: 2 Y <br /> APPLICATION ACCEPTED BY <br /> TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTIONY <br /> � C ATE �` / <br /> pp <br /> llousf­ <br /> ADDITIONAL COMMENTS:_ I%/`/Y "'YI I - ' <br /> ACCOINTINO ONLY: <br /> BND/ FACT <br /> PE CODE FEE INFO AMOUNT ROMITED HEC /CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE <br /> Pub.Health Serv.•Enviro.174(3/96) <br />