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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complttt M Trfplktt/) APPLICATION 19 HEREBY MADE TO THE SAN JOAGU9N COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COW UA14CE WITH SAN JOAGUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110 3 AN THE STANDARDS OF SAN JOAGUIN COU PUBLIC HEALTH SERVICES,ENVIRONMDIVISION.ENTAL HEALTH DIVISION. JOB ADDRRESS/OR APNI O I C-✓14 J / CCTV Gy— (-,�/(,- LOT OWNER'S NAME � ✓" /~�`^�'`', ` ADDRE199 ��jJ PHONE CONTRACTOR /L///T7 17n 7�// .s�C. ' ADDRESS Ch^� 4�/ LIC( Z") ��N '• ADDRESS LIC( PHONE SVB CONTRACTOR TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BU O-) PERC TESTUI I I HOW MANY AppSomren# INSTALLATION WILL SERVE: RESIDENCE `V COMMERCIAL❑ OTHER ❑ NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMEER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET PIT/BUMP SOIL CHARACTE TER TABLE DEPTH �� \ SEPTIC TANK/OREASE TRAP 11 /M TYPEFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) C LEACHING UNE ❑ NO.a LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE FILTER SW ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE V SEEPAGE MTS ❑DEPTH SIZE NUMBER__DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE i SLIPS �NIDTH.Z_LENOTH�DEPTH DISTANCE TO NEAREST:WELL-A5— O FOUNDAMN.; � PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LME 1 HEREBY CERTIFY THAT 1 HAVEPREP THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWB,AND RULES AND REGULATIONS OF THE SAN JOA COUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH Tme PEWMIT It ISSUED,1 SHALL NOT PLOY ANY PERSON IN OUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN't COMPENSATION LAWS OF CAUFORMSA.' CONTRACTOR'S HIRING OR SUS-CO URE CERT 9 THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IO ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO M CO T N LAWS /IIT 111 TIREJA;" MUST CALL 24 HOURS IN ADVANCE FOR A—LL' pAoUntED INSPECTIONS. COMPLETE DIUWNNG BELOW (� TITLE: l DATE: NED X PLOT PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS R ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED (� 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION- EXPANSION F SEWAGE THIN019PRA L SYSTEMS• 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION T WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PRIDPERTTY ... ..... .. ..........;..........•...:..............:........... .. :.. ...... ......:......:.......c............t......;.. :.. .:.....:.....:.....:. f. . ..:......:.. ..: ............. ...............:.. ...: ........................ ...........:.... -. ..... .. .:.. ..:.. ..:: .. :......:.......:......;......:..............:....•..>.... . ................... . ..... . ....°.'......... Z S .r.. .........;.. .......... .. .. .. .. ................ ..:... .......;...........•.:......... .. .......... ........ ...?... ..:..... ........................................<.......:.......;...... . .. ;......;.....;.............<......._....<...... .. .. .. . .................... : . - .. : ; .. .. .. .. L ........: ......................n ............ ;...............�...............;............ .......... ........... .....:.... ..LV . .dam' NTY•P4IBLIC HEALTH SERVICES.._.........lo*OU ....:>............;..... ...'.....<..............:............ .......:....................:. . . ... ...-.......>. . . ...........................:.........:. . ......:.............:............. .....: . .............................. ......:............ .......<......: .. ....... .............<. ...... ... SPECIAL PERMIT ....... :... _. .. : � .. 1�(I.]�1�OA EPARTMENT USEONLY APPLICATION ACCEPTED BY A /Q 1 M,/ �'�" " DATE: AREA: TANK,PIT OR SUMP INSPECTION BV DATE / / FINAL INSPECTION BY ATE 1` ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAG PE CODE FEE INFO AMOUNT ROASTED CIMCK#/CASH MOVED BY DATE SII/PERMT NUMBER INVOICE# Pub.Heakh Serv.-Enviro.174(3196)