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APPLICATION FOR LIQUID WASTE PERMIT jAN'JOAOUIN COUNTY PUBLIC HEALTH SERYL,s ENVIRONMENTAL HEALTH DIVISION P.O. BOX W8, 304 EAST WEBER AVENUE, STOCKTON, CA 9Sn't-M (209) 469-3420nn _ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ---� (Complete in Triplicate) APPLICATION IS 14ERE13Y MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THEfTANDARDS OWSA)JOWAOUN COUNTY PUBLIC HEALTH SERVICES,ENVIIRONNMMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# � C� CITY [.G��tff�z LOT SIZE/7/9 OWNER'S NAM �'lD`=� .1. ADDRESS PHONE CONTRACTOR ' / ADDRESS LIC# PHONE SUBCONTRACTOR /I_��O�C-� �l.�l� ADDRE86 Ill C JIJ.-t/l� It(.�- - :tel '�� UC# PHONE fq TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ TION.�I IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.I FILL PERC TESTI*I I 1 HOW MANY (� Application# ��'✓)\/I[-i\� I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ ,. NUMBER OF UVINO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/BUMP SOIL CHARACTER: WATER TABLE DEPTH ;+ice J jJf ICiI SEPTIC TANK/OREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS i 4,ljL'I PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE -�/�N JUriUV�iv:;UUNTY U —�Q�LIC'fiFAUH SERVICES FT STATION❑ SIZE TYPE Of PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) �NVIPONMFNTAI, HFA(TH OURION LEACHING UNE ❑ NO.i LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE BLIMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE V` I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISS SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACT 0 SIGN URE ERTIFIEB THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S MPENSAT N WS CALIFORN THE APPLICANT MUST CAL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: DATE: PLOT PLAN(DRAW TO SCALE)SCALE "to 1. NAMES OF STREETS O ROADS NEA T TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PRO PE IMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. TA .......... 00 :.. .. ., . . ,- Q :. .. � S .. .. .. . . .... ..:... ..:. .... : . ..... . .. : : ............ .. ...:....... .. .:.. ..:. .. . :... .:. ... .. ....... . .. . �ry�-"�� /�(�j� ^r_ •�� 'fOR DEP�IRlI�Iua USE ONLY 1 1 / APPLICATION ACCEPTED BY $_� DATE: AREA: AREA: v/ 0 1 - TANK,PIT OR SUMP INSPECTION BY (!' y DATE / ! FINAL INSPECTION BV DATE ! / ADDITIONAL COMMENTS: Q f�b/yfN 3 �` .♦•uC/LvK./ j�tl,,Id.Z.� `� T v ACCOUNTING ONLY: AID# FACN PE CODE FEE INFO AMOUNT REMIT E CHECK#!CASH R EIVED BY DAT $R/PERMIT NUMBER INVOICE# `� a / 00' 02W35