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APPLICATION FOR LIQUID WASTE PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (C{Inpl{t{IR Trpll-{h) APPLICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAWIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.7 AND THE SANDAAJRID/B/.DIF S/JI JOAO�UJ17 COUNTY PUBLIC HEALTH SERVICES.LENkV1yIRONM MAL HEALTH DIVISION. JOB ADDRESBlOR APPHI �-L� Cif/ l U/IJ�C�// CNV �X'1�I�✓E LOT 812E,1�20 Aev, OWNER'S NAME/!-J..I'�//I /'CL/ ADDRESS��M D PHONE CONTRACTOR/C/-J�1/I/�� C//LItlL^.Ti ��IADDRE.. �Q��-� 17Y��% J UCJ 6 PHONE T / BUB CONTRACTOR ADDRESS UCI PHONE TYPE OF SEPTIC WORN'. NEW INSTALLATION RE P A I R' . DITION❑ DESTRUCTION❑ INE SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WNIIIN 200 FEET OF BUILLING.1 RRC TESTIH I 1 NOW MANY INSTALLATION WILL{ERNE: RESIDENCE yR COMMERCIAL❑ OTHER ClNUMBER OF WINO UMTS:_NUM--,BER..BEDRO/OM/{J: Z Nw.N1 OF B.IPLOYFEA: CHARACTER OF SOIL TO A DEPTH OF J FRET: /7/"t//iL�PIT/BUMP 601L CNAMCTER: C CC. WATER TABLE DEPTHY-- {EPUC TANK/GRIIA-E TRAP ❑TYFEIMFGde .4!9!Z e-'- CAPACITY, �i IS/) NO.COMPARTMENTS PKG TREATMENT FLINT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SITE TYPE OF RUMP SAND OIL SEPARATOR(ENCLOSED BYBTEMI (( DISTANCE TO NEAREST:WELL �/ ��R101SRTY UNE '// !/�/ LEACHING UNE NO.•LENGTH OF UNEB I FOUNDATION FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED 0WIDTH LENGTH DEPTH DISTANCE TO NEAAEST:WELL / FOUNDATION PFKIPEHTV UNE {FEIAGE RT■ ,OI DEPTH 1--5— St. .�G/ DI NUMBER -E/ STANCE TO NEMIEBT:WELD/s'n' FOUHOATIONPFIOPERTY UNE /�T {UNP{ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE _- O.PO-AL POND- ❑WIDTH tENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAH JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES ANO REGULATIONS OF THE SAN"AWIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTNIEBTHE FOLLOWING:-ICERTIFYTHAT IN THE PERFORMANCE OF THEWOW FORWHICH THIN PERMIT IB ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR 808 CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO _ WGWMAN'e CTOoMPENN'S-ATI�ON LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALLREGURIEG INSPECTIONS.COMMETE DMWINO BELOW. SIGNED X/! "_.i TRIF: � �/ GATE: I� 7 PLOT PIAN(DRAW TO SCALE)SCALE_ 1.NAMEB OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 1'4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. G.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 8.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON F INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYB,AND WALKS. THE PROPERTY OR ADJOINING p11OPERTl'. Ca O P C,' 2-•/� b 4..' Tom. NF_ R4V p . . ENVIRUr i, 1L 'r:-u 7H f11V151�.1I. �,1I��1� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �` ��V F % DATE: / /I AREA: �7� ' TANK,PT OR BUMP INSKCTIC14 BY DATE I / FINAL INSPECTION BV U DATE !/�'! ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDJ FAC• ��,/,L/�.J 3 PE CODE FEE INFO AMOUNT REMITTED CIIECK/ICA{H RECEV NY DATE M I PERMIT NUMBER INVOICE F Pub.FAR."So--E—ro.174(3/96)