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3: ' APPLICATION FOR LIQUID WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 466-MO NON-REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED gampIBt,In TripRBBTB) APPLICATION 10 WAMY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION M MADE IN COMPLIANC%WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESBRIR nkPNI i2 R`J _� b COY U LOT BITE OWNER'S NAME 44 -' ADM$$ PHONE - ^ CONTRACTOR S%G:l�l L � r�-� 1-5ke owomse z -/e &1 1j5k,,N✓,'C-1 ucR '+- ftwo @US CONTRACTOR ADDRESS LTC/ PMONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPADVADO1TION A DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDIVG.1 PSIC TEBTNI I I WAN MANY APyBoWaR f� INSTALLATION WILL SERVE RESIDENCE M COMMERCIAL❑ OTHER 0 NUMBS<OF LINO UNIT@: NLWA'IM OF BEDROOM$: NUMBER OF EMPLOYEE#_ CHARACTER OF 90 L TO A DEPTH OF 3 FEET._ PITMUMP 9011.CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASE TRAP ❑TYPEIMV CAPACITY No.COMPARTMENTS FKD TmAtMENt PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY PINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACRSNO LINE 0 NO.A LENGTH OF LINES_Y^ 17 r DISTANCE TO NEAREST:WELL/a U FOUNDATION Va PROPERTY LINE Q FILTER BED cl WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH_ DEPTH DISTANCE TO NEAIESr;WELL FOUNDATION PROPERTY LIVE BEEPA0E FRS ❑DEPTH SIZE _NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 717—@uMPs m WIDTH LENGTH /Gl`DEPTH DISTANCE TO NEAREST:WELL i J_FOUNDATION -/f)�PROPERTY LINE /[] r DISPOSAL FONDS ❑W MTTR LENGTH _DEPTH DISTANCE TO NEAREST:WEM_FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE%%VM WILL BE DONE IN ACCDNDANCE WITH PAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE BAH JOAOMCOUNTY.HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLONANO:'I CERTIFYTHAT IN THE PEREONBIANCEOF THEWONL FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AR TO BECOME SLISJECT TO WORKMAN'@ COMPENSATION LAWS OF CALFFDFIM.' CONTRACTOR'S HIRING OR SUB-CONTRACTW$SIGNATURE CERTIFIES THE FOL.LDVVM,.'I CERTIFY THAT IN THE REIRFORRMANCE OF THE WORK FOP.WHICH THIS PERMIT 19 IBSIRO.I IiWl EMPLOY PERSONS SUBJECT TO WORKMAN'@ LAW@ OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REamilo INSPECTIONS. COMPLETE DRAWING BELOW- �y BIO COMPENSAT H BELOW- SIGNED% TITLE:_ DATE: PLOT PLAN(DRAW TO BCALEI 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.WITH DIMENSIONS AND NORTH DSIECTIOH. EXPANSION OF SEWAGE DISPOSAL SYSTEMS- ]. DIMENSIONED OUTLIVES AND LOCATION OF ALL EXISTING AND PROPOSED(STRUCTURED, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR AOJOIVINS PROPERTY. ;., .,.- . . ,�` k ....... ........,.. . ti ' . ..... . ...;. .. ... .. ... .. ...... `. Zt....... - .............. /V. 1 .. .. ... ..... ..... . o ,...;. s .......... r i . :....f ... .:... .... i i . . r iTROYiyxfvI� r IuUirvcru ;. M NVI R ONMEy i Al.HEPLTH.DIVISRA f FOR OFYARTMk7RT USE ONLY APPLICATION ACCEPTED BY DATE: f+ AL'EA: TANK,PIT OR SUMP INSPECTION BY DATE I !. }- 'FINAL INSPECTION BY-77 OATF Z� ADDITIONAL COMMENTS: _�,-e0do N D RTN S D �Ii rI �t�f5� 12a�GaO ACCOUKIPA0 ONLY: AID/ FACT 21 PE CODE Fff INFO AMOUNT REMITTED CIfEC ASH IIECEMFD BY DATE OR r PERMIT NUMSM INVOICE 0 ro s - d 22i Pub.Health Serv,-Enviro.174(3W)