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PLICATION FOR LIQUID WASTE PERMIT uU SAN MLJAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICBmpIBla In Triplicate) APPLICATION It HEREBY MADE TO THE BAN BOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE BTANO/A�RDa OF SAN JOAQUIN COUNTY PUBLIC HEALTH SS�ERVIIICC�E@,/ENNVIRONMENTAL HEALTH DIVISION. JOB ADDREGB/OR APNS I w t S / It P J lc 1a CRY 1�I r/)1 1 LOT SIZE ;;L!'i OWNER'B NAMEr S C4!4 --ADDRESS fl�)'C'yNe-1 [' PHONE �.J�t�'-L.•.�J�J� CONTRACTOR /�j� I �c (t+ __ ADDRESS}'(� (J �CW 1 C� _LICE�[ j]�'j_']_PHONE, !"7-7 7 3 BUB CONTRACTOR ADDRESS UC/ PHONf TYPE OF SEPTIC WORN: NEW INSTALLATION REPAIRIADDITION❑ DESTRUCTION❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILT NO.) PER.TUTU(1 1 HOW MANY &?--COMMERCIAL . .�/ Apptp4tpR/ INSTALLATION WILL SERVE: RESIDENCE& COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITS:NUNIA 1 Of BEDROOMS! NUMBER OF EMPLOYEES: CHARACTER OF BOIL TO A DEPTH OF1�3 FEET: .l�`^L.E�. PR RA /BUMP SOIL CHARACTER' S ^^C WATER TABLE DEPTH SEPTIC TANIUMEASE TRAP y',r—[IMFO IQ 4-L- CAPACITY O NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION 15 F PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED BYSTEMI LEACHING LINE NO.S LENOTH OF LINES .Y. - 4S'1Y DISTANCE TO NEAREST:WELL I(S A T FOUNDATION PROPERTY LINE -7 5` r FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIOTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SE17AGE PIT& 13 DEPTH_SIZE NUMBER DISTANCE TO NEMER:WELL FOUNDATION PROPERTY LINE BUMPS 0 W'IOTH �LENGTH DEPTH I O I DISTANCE TO NEAREST:WELLFOUNDATION WOPERTY LINE DISPOSAL PONDS ❑M OTN LENGTH DEPTH DISTANCE TO NEARER:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOFK WILL BE DONE IN ACCORDANCE WITH BAN JOACUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANDREGULATIONS OF THE BAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AOENT'a SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THEWORK FOR WHICH THIS PERMIT la ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOFKMM'B COMPENBATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB�CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHAM.EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAW@ OF CALIFORNIA.- THE APPLICANT MUST CALL 24/ORS IN ADVANCt FOR ALL KSO"IED INSPECTIONS. COMPLETE DRAWING BELLOW. SIGNED K ALL TITLE. C��P C--C �A I1 DATE: -1 PLOT PLAN(DRAW TO SCALE)SCALE_'Ip 1.NAMES OF STREETS OR MOADS NEARER TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR pnopOBED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNEB AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTUREB, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WHIRS. THE PROPERTY OR ADJOMNFO POFERTY_ pS'^ lir`;:' DEC 15 1998 - .._ SAN.CAATN^,UUN 1,( .. AAAA . T iJ 1 PUSC L, HEALTH SEFi•'ICE;. ' .. .� W'�tl ENVIRCN/AENTAL HEALTH DIVIL,1r- -- - — .. / 1r� FOR EPM TMENT USE ONLY APPLICATION ACCEPTED BY \ C \ DATE: A: TANK,RT OR BUMP INSPECYIOH BY DAT FINAL INSPECTION BY T�L� ADDITIONAL COMMENTS: ACCO UN TALO ONLY: AID/ FAC/ PL CODE FR INFO AMOUNT R6M ITFO ITEC /CASH RECflVFD SY DAT[ N/►9N11T NUNBBI INVOICE 1 f Q' Pub.Health SerV.•EDviro.174(3/96)