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APPLI' ON FOR LIQUID WASTE PERMIT /--v ( � f SAN JOAQU-,4 COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ��;� 3 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED IComplala in Triplicate) 'LIGATION 18 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 ,QUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. AG, �I /�7 Q CITY GLF-(� 5 LOT SIZE ADDRESSOR APNI �/p� I'-'t \K� 1� `� /f LST .,,{�-�J /- C�r��1 -.I aO �-A\ C7Uf�ly� ADDRESS ^O�OO � \l RI��S �Q Glr�l�lt--`T�� PHONE WyO •�l I^��IO NER'S NAME t (j, �L`A�.�1V��.�jRQ,E UCF —PHONE_ AADDRESSJTRACTOR l^tA ' �'``w I—rn O UC, PHONE ADDRESS 3 CONTRACTOR 'E OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCT) pETRC TEST(.)I I HOW MANY 7 SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Apppatlon TALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:_ ,YIBEfl OF LIVING UMTS: PITlSUMP SOIL CHARACTER: WATER TABLE DEPTH ARACTER OF SOIL TO A DEPTH OF J FEET: CAPACITY NO.COMPARTMENTS *TIC TANK/ORIEA6E TRAP ❑TYMMFO PROPERTY UNE TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE .GRAND UNE ❑ NO.S LENGTH OF LINESDISTANCE pfiOPERTY LINE TER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL UNDER PROPERTY UNE PAGE MTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION FOUNDATION PROPERTY UNE MPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATgN PROPERTY LINE POSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL .REBY CERTIFY THAT 1 HAVE PREPARED TH19 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES D REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFYTHAT INTHE PERFORMANCE OF THE WORK FOR WHICH e PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR 3-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO .WMAN'B COMPENS ION LAWS c��THE ICANT MUST CALL 24 HOURS IN ADVANCE FOR ALLL REQUIRED INSPECTIONS. COMPLETE DRAWING/BELOW' p)0 TITLE: O w(� � DATE: NED X PLOT FUN IDRAW TO SCALE)SCALE_ -10 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON NCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ....:..... :... .............................:..................................... .: :........... ...... .. .. ................................. ........ ...... .. .... ... _.... .. _:.... ......:............. .... ............. __.... L7.....S.E��IG ' AtaK �a OE:_t��I"twF-!� ......... : .... .. ....... N ...: ...:...........:.... ......................:.....:......<..... ... . ....... .:... . . ........ ...i .....:.......:.... .. _. :... .:.. :........ .. .. ....... ..... .. .... .... ........... ......... .. ... :......:. ..:............. ...:......:........................,.... .. ........... . .. ._ ..:. .:... ...... .... 1�1• Iyfn f.. ........ ......... ... ... ...... .............. �� 7.. 1 .'tea ..:- _ PES1Eall. T- .r.i1LU 11N SENVROiNMENALHEAL HIII. ............. F .: ..._ �IIVcSIS .. _._..._ ..; .... .. ... SEPTtC. '`AKK TO...P�>w '..R Mav�p . . ... . . . __ 55 �� FOR rU1OFPAP ENT USE':NLf --_—. 'UCATION ACCEPTED BY �V �✓f L� �./1./�-^�� a-= !� I _ -� A a !MC,P17 OR SUMP INSPECTION BY DATE / FINAL y^, Da', DITIO NAL COMMENTS: ell _ - ACCOUNTING ONLY: AID/ FAC# PE CODE FEE INFO AMOUNT REM ITED CHECK ICASH I RECEIVED BY DATE an I PERMIT NUMBER INVOICE Pub.Health Serv.-Enviro.174(3/96) (SSC S I