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Z # — APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SEF � ENVIRONMENTAL HEALTH DIVISION !r ' 304 EAST WEBER AVENUE:, STOCKTON, CA 95202 , (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED { {��)J]��►►► ICompl@t6 In TrlplWt61 APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATKIN 19 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDA 8 OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES, RONMENTAL HEALTH DIVISION. -.. f/ jJ,E{J� �j�e JOB ADDRES8/0R APN# � l //L CITY r��I AFhK--��'L. LOT SIZE �`" OWNER'S NAME ! SCJ L' ADDRESS • / '/v , I _ PHONE CONTRACTOR SY�/ ADORES' LK:/ RHONE SUB CONTRACTOR ADDRESS VCR RHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ SHD SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.? PERC TFATIsl 1 I NOW MANY AppReotlon! INSTALLATION WILL 6ELYE: RESIDENCE❑ COMMERCIAL I, OTHER❑ [✓Ilr ^' 1��,II�' �r� '`// .J/,, NUMBER OF WINO UNITS: OF BEDROOMS: NUMBER OF EMPLOYEES. o,zr j4,, �.� I�SN1 r7''T� 'r t k CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PTTISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PRO TREATMENT PLANT_❑ DISTANCE TO NEAREbT: WELL FOUNDATION PROPERTY UNE [TFT STATION 0 SIZE TYPE OF PUMP SAND OIL SEPARATOR[ENCLOSED SYSTEMI LEACHING LINE ❑ NO.Q LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER RED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I' MOUNDED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I SEEPAGE RT6 ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FFF sumps ❑YYIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULE; I AND REGULATIONS OF THE GAN JOACK03M COUNTY.HOME OWNEFLORUCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING''ICEFMFYTHAT IN THEPERFOPMANCE OF THEWORK PORWHICH THIS PERMIT is ISOM,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'@ COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'B HIFUNG OR a 8UB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIREO INSPECTIONS. COMPETE DRAWING BELOW. ` ll STONED X TITLE: J,'n�f,•.e� DATE: k ! I PLOT RAN(DRAW TO SCALE)SCALE_' 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF GROUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 1 2, OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADII'OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS DFWEWAYS AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. i .. -.__..-.,e.... ..... ....... .......... ..... ..., ., ... ., - .. .. .. .. -. _ ... i ....,: . :....... :.... .. :........_.-- -- ..:..,..... :.. - .. -. .. .. .. ..... ............ .. -- 1 .... :- ...E. ........ .. .. ., - .. .. Ile :.,... ....�.. h! .. . i : ?ECE1!!ED ......... . .. ... ....... . . Ffg 15.2 00 :. . sm ... . 7 eq , .....;. . V�RR7NA�E�A�N�q 14" oly . ,2-7277 ........ ............................................ ........ ....... ...... APPUCATIONACCEPTEDBY 1 TANK,PIT OA SUMP INSPECTION BY / DATE ! ! FIDiAL IN8PECORON 8Y r -- DAT€ - T�j`` - ADDITIONAL r CE ACCOUNTING ONLY: NDI FACT PE CODE FEE INFO AMOUNT REMIITED �IICASH RECLIVEbBY DATE 6RIpawl.NUMBER INVOICE0 t Pub.Health SerY.-Enviro.174(3196)