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APPLICATION FOR LIQUIO WASTE PERMIT <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 1$MADE IN COMPLIANCE WITH BAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOA N COUNTY PUBLIC HEALTH SERVICES, <br /> ENNVIRO /LL HEALTH DIVIOON. <br /> JOB ADDRESSOR APN/ Z� CRY`J / r'/t+/�/ 64 ♦ LOT SIZE/ /QGei <br /> � ' PHONE <br /> OWNER'S NAME-211zADDRESS 1, — <br /> 1_21 <br /> _2 / - PHONE <br /> CONTRACT �/ .eADDRESS LIC/ <br /> T'I/� ✓ �T' <br /> BUB CONTRACTOR ADDRESS LIC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Nry DESTRUCTION ❑ <br /> tNO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) PEIC TSSTUI f 1 HOW MANY <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL❑ OTHER❑ <br /> NUMSER OF LIVING UPNTS:--/ NUMBER OF S OMB: NUMBER OF EMPLO - <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: Q ATER TABLE DEPTH <br /> SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS <br /> PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING LINE ❑ NO.a LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> SEEPAGE FITS �0 <br /> y1DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE n <br /> SUMPS WIDTH / LENGTH DEPTH_DISTANCE TO NEAREST:WELL FOUNDATION 51 LINE <br /> DI$►OSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> 1 HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAI JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAGUIN COUNTY.HOMEOWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING!*1 CERTIFY THAT INTHE PERFORMANCE OF THE WORK FORYMNCH <br /> THIS PERMIT IS ISSUED,I$HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALWOIMMA.- CONTRACTOR'S IBT$NG OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWOM:M CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1$ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COOFC RMh' A►MICANT MUST ALL 24 MOUIRS IN ADVANCE FOR ALL REGUBIED INSPECTIONS. COMPLETE DRAWING BELOW <br /> 810NE0 X <br /> TITLE: DATE: <br /> PLOT PLAN(DRAW TO SCALE)SCALE 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. 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EALTk Sc l R ICeS: <br /> ;......; <br /> ... ... ... <br /> LTM <br /> .......:..............:. ..:........ENVIFtpNNTE DIVISION: <br /> H ' <br /> NTAL FLEA <br /> J�� �y/ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By Y7L j'�7�"7�i K1L� !/ -Q� DATE: �O 4 AREA: <br /> TAMC,PIT OR SUMP INSPECTION BV DATE / / FINAL INSPECTION BY �i� �/ , '/C DATE � <br /> ADDITIONAL COMMENTS: �/�1.. ✓'...•,<- '�' .• �� - S t,�f'I G -t�2✓1 I »i--i, 'TO IO1,SSI <br /> 6 LP <br /> ACCOUNTING ONLY: ADI FAC# <br /> re CODE FEE INFO AMOUNT`ROM ITED Cl— /CASH RECEVED EY DATE $R I PERM I NUMBER INVOICE# <br /> o <br /> 0A /6 <br /> Pub.Health Serv.-Enviro.174(3/96) <br />