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LIGATION FOR LIQUID WASTE PERMIT SAN OUIN COUNTY PUBLIC HEALTH SEF, ES py ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 c (o (209) 468-3420 111011•REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 19 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 JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110..3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/ ( �/ GsJ rJ l`.//l;iI 1 V CITY /!7/1,/t ,rte--C% LOT SIZE' -`�, S✓ OWNER'S NAME /�. t i tY i,� •� ADDRESS j — t� �9:/:i.'J ,'C �r1 PHONE CONTRACTOR i�. /--i. l [ (/�� ADDRESS L��i ; �+��'� T�%/?::ra LIC#.-�.� 7^�l]y� PHONE L�.S•:� ✓�� SUB CONTRACTOR ADDRESS UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIvI I 1 HOW MANY Appamdon# INSTALLATION WILL SERVE: RESIDENCE% COMMERCIAL ❑ OTHER 11NUMBER OF LIVING UMTS:_ NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYP£/MFG � L r CAPACITY /J�% NO.COMPARTMENTS OL PKG TREATMENT PLANT 1:1DISTANCE TO NEAREST: WELL_. FOUNDATION__/.-L�-7 PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI �' DISTANCE TO NEAREST:WELLrFOUNDATIONC-%�/ LEACHING UNE ❑ NO.A LENGTH OF LINES / C' -� PROPERTY UNE I FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE NTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE \ 1 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 \•� AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFYTHAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAW#OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-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 WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNEDX ��-�-�-�-s _TITLE: V ,-iL /_ ,�Z�»- OATE:� � PLOT PLAN tDRAW TO SCALE)SCALE_.-M - 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED -v 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. 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. .......... .. : I .. fl _..... .... . .....v.� ...:.. J:.. ........ .. . • A .. . �, <....... ....; ...:.. ...............................,... .. ..... , ✓� • = 4 .. .. .....:.............:.... .... .. ..,.'� ..� k .. �.J' .. .. ............... ... .. _ ... ...:.....:...........:......:.......... " .. .. .. .. .. .. . ( r - .. .. ......:.....:.....? ....:...........:.....+......:..... V Ee/u1 ......! .. r .. PAY -E :.: ......... .. . . SES 7 199 .. ......... . .. ..................L r SAr, IUP eIJiPJ UutJ7`, it .�. .......... \ / _.. . . PLIfar' IfDtPHS��i'J1C:IT•i .. i FOR DEPAPTMENT USE ONLY ^ / APPLICATION ACCEPTED BY —l DATE: / AREA: lr� QO TANK,PIT OR SUIy1Q LSCTION BY / DATE / / FINAL INSPECTION BY DATE /Z ADDITIONAL COMMENTS: ` ACCOUNTING ONLY: AID/ FAC# PE CODE FEE INFO AMOUNT REMITTED HEC /CASH RECEIVm SY DATE RLR/PEIMIT NUMBER INVOICE# 0 Pub.Health Serv.-Enviro.174(3/96)