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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 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 JOAQUIN COUNTY DEVELOPME TITLF,CHAPTER 9-1 1 10.3 A E STANDARDS O N JOAQUIN CO Bt1eHEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# [ 1 Iry LOT SIZE 1r� I,�;W•`= OWNER'S NAME -- ADDRESS i / �� (��1 PHONE yj CONTRACTOR ADDRESS LIC# PHONE SUB CONTRACTOROZZ A L .-A ADDRESS / � ' J� �� UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUC ION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(S)I 1 HOW MANY Apoloatlon� INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ NUMBER OF UVIN13 UNITS: NUMBER OF BEDROOMB:�_ NUMBER OF E3MPLOYETA: I CHARACTER OF SOIL TO A DEPTH OF 3 FEET: �l PIT/SUMP SOIL CHARACTER: ATER TABLE DEPTH e SEPTIC TANK/GREASE TRAP ❑TYPEIMFG CAPACITY �. NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATIO PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMPSA OIL SEPARATOR(ENCLOSED SYSTEM) 1 LEACHING LINE �NO.&LENGTH OF LINES (STANCE TO NEAREST:WELL �` FOUNDATION_l PROPERTY LINE_ 7- FILTER FILTER BED ❑WIDTH_ LENGTH_ DEPTH_ DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH_ _DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE Q SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WRH 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:"I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I 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-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CoA NSATION LAWS OF CALIF(RNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X il� IC�„�✓ � �� ,�� TITLE:�i 2 �� `�` DATE: PLOT PLAN(DRAW TO SCALE)SCALE "to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,V41TH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. 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. . int ................... :. :.. :.. ... .. ........... . _ . .. .. _ ! _. PAY 0.c -0:1995. . .. . . s AN.JUACCI... IV Ur T� PUB.LI ..HALTH SERDICES C . .. NVIRONMNTAL.i.EgLTF{pli/IStON FOR DEPARTMENT USE ONLY \� .r APPLICATION ACCEPTED BY�"\� �� DATE: ) t' / �` 1 � AREA: > 1 TANK,PIT OR SUMP INSPECTION BY 1 DATE / / FINA/L/}INSPECTION BY DATE ADDITIONAL COMMENTS: L , I A.j� ' I�f-4(,` (^�l�,r�l ISI ('•N l /1 G F-l- //'{.-KL�L ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE 0