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APPLICATION FOR LIdUID WASTE PERMIT JAN JOAQUIN COUNTY PUBLIC HE:ALTt. SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,.STOCKTON, CA 95202 (209)468-3420 OR-REFUNDABLE PERMIT JXPIRES 1 YEAR FROM DATE ISSUED FILE ICempbLy in Triplk$td APPLICATION 18 HEREBY MAOE.TO THE SAN JOAOUIH'COUNTY FOR A PERMIT TO CONSTRUCT AN DJOR INSTALL WORK DESCRIBED. THIS APPLICATION IS MAGE IN COMPLIANCE WITH BAN JOAQUIN COUNTY 13114LOP1-7-3.3.3 MENTaTI�TTLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENWRONMENFAL HEALTH DIVk810N. JOB AVORESS/OR APP) ! -7✓J.3c m ra ox �1 /t CITY -.71 / - LOOT SIZE C. PHONE - 0 OWNER'S NAME ADDRESS �3 / L O/GF L C>/V '.1( •' LO �yy ADDRESS - LIC# ,PHONE, CONTRACTOR C )V✓ - _ - ' - _ .LIC#-PHONE OUR CONTRACTOR ADDRESS \_ TYPE OF SEPT,C WORK: NEW INSTALf.ATION Cls AEFAIRIADD1710N ❑ DESTRUCTION ❑ - PL3R0 TEST401 I 1 NOW MANY IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING-1 AppSntlon/ INSTALLATION WILL COWL- RESIDENCE❑ COMMERCIAL❑ OTHER' �R�� t• '� C- -Tp p`� �� NUMBER OF UVINO UNITS; NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP D TYPE/MFO CAPACITY NO.COMPARTMENTS t PKG TREATMENT FtANT❑ DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY LINE I UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR{ENCLOSED SYSTEM) V I LEACHING LINE ❑ HO.A LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ITLTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPEFITY LINE MOUNDED 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE \^�' SEEPAGE FITS ❑DEPTH itiE BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH UNOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE - 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,ANb RULES AND REGULATIONS Op THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FORWHICH THIS PERMIT IS 1$BUEP,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAW@ OF CALIFORNIA.' CONrRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOVMNG:M CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHRM ICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'*COMPENS^TION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE MRR�ALL REQUIRED INSPECTION$. COMPLETE DRAWNG BELOW' �! SIGNED XTITLE: l../.�1J14!�� DATE! PLOT PLAN[DRAW TO SCALE)SCALE 'to 1. NAMES OF STREEIrs OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. i L AN - - 1 :. . ..... .,.......,..... ..... ...:.. r :....... .. .. s I 0. " .. , -X99 ........... ��0 1 A 9-,�-- L"C:j .. . �m a glktlJC3f�' 5 f. ' tiNV4t�OS�. ! " .,.. 4 i .... . r FOR DEPARTMENT USE ONLY C J II APPLICATION ACCEPTED BY ` RATE: ✓ AREA: � TANK,PIT OR BUMP IINSPEC710H BY BATF / ! FINAL INSPECTION aY DATE ADDITIONAL COMMENTS:_ - 2LI L2 1 c)h- 1/-I&•9$ • SITE VISri �113�� 1�t� >;El.uuuK RCa �;SED-d ,caca ADurse�o f�sR Pte- R� � s Vt ACCOUNTINGOM�Y: AID# FACS uQ rl"p� 7b �r5�Hd1t4dL zv PE CODE FEE INFO AMOUNT RMNITED CIIECKSICASH RECEIVED BY DATE SR►PERIMIT NUMBER INVOICE# Pub.Health Sam-Envrra.174(3/96) RAI E -r,4',Hk Te I-to--G