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APPLICATION FOR LIQUID WASTE PERMIT SE., JOAQUIN COUNTY PUBLIC HEALTH 5_-tVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED, THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1 1 10.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. $-/Op 1// NIC/Y /L CTY �Di LOT SIZE JOB ADDRESS/OR APN//�' �/ N� �• J I, 7 OWNER'S NAME �j 5-loo L� /4W a /� PHONE G11Z }� ADDRESS V�-�,,-`,1 CONTRACTOR Vit " i MUI f1fk( ADDRESS 1�S V� KC-T�'1`44� (^N 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.) P9tC TESTI�I l I HOW MANY Appilmdon l INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER❑ NUMBER OF LIVING UNITS: NLWABER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/BUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM1 LEACHING LINE ❑ NO.6 LENGTH OF UNES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BLIMPS FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL I 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 UCENSED AGENT'S SIGNATURE CERTIFIER THE FO LLOWINO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANV N4NVVCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR THIS PENTRACTI S ED,SIGI S URE CERTIFIES LOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS AUFORNIA.- THE APPLICANT MUST CALL 14 HOURS IM ADVANCE FOR ALL REQUIRED INSpt<CTIONe. COMPLETE DRAWING BELOW. I j3o TITLE: 1 •7'xQN DATE: SIGNED X PLOT PLAN(DRAW TO SCALE)SCALE_ -to 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 5, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr.ON 3. DIMENSIONED OVTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, THE PROPERTY OR ADJOINING PROPERTY. INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ._ .. . _. i .. . ..`.... .. ....... - ..:.... :... .. ...... _......... ...... 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ENVIRONMENTAL HEALTH DIVIS(O1J ...:....... ...:.... nn FOR DEPARTMENT USE ONLY �L// / �j APPLICATION ACCEPTED By DATE: AREA:- DATE /0 DATE / / FINAL INSPECTION BY TANK,PIT OR SUMP INSPECTION `i7177 ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID/ FACS PE CODE FEE INFO AMOUNT REMITTED ITEC /CASH RECEIVED BY DATE !PST NUMBER INVOICE'r z Pub.Health Serv.-Enviro.174(3/96)