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.�APPLICATIOR FOR LIQUID WASTE PERMIT S�. lOAOUIN COUNTY PUBLIC HEALTH SL ,DICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 py NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DA E SSUED (Complete M Triplicate) APPLICATION IS HEREBY MADE TO THE BAN JOAQU!N COUNTY FOR A PERMrT TO CONSTRUCT ANO/Oq INSTALL THE WOGS(OESCRIBEb. THIS APPLICATION LS MADE IN COMPLIANCE%MTN BAN JOAOUIN COUNTY DEVELOPMENT TITTLE,CHAPTER 9-1/1-�10.,3�AAN`D THE ST`AN/D�ARbB OF BAN JOAQUIN COUNTY PUBLIC HEALTH BERVrCEB.INVIRONMENTAL HEALTH 01%MMON. JOB AbQRESS/OR API+)— -7p/ - Jr. l/c ,611 -_ A- �.,.. .CRY L—:SC.'lc,H LOT SITE l�t JONE JyS Y /E L� ti- ,/ � / COWNFR'S NAMQom.• CONTRACTOR , lf" ADDRESS LIC) PHONE SUB CONTRACTOR ADORESB LIG► PHONE TYPE OF BF.{RIC WORK: NEW INSTALLATION © REPAIR/ADDITION (3 DE/TRUC MO SEPTIC SYSTEM PERMITTED IF PUBLIC SEINER IS AVAILABLE WITHIN 200 rw OF BUILDING.1 PEIC TESTUI 1 1 HOW MANY i Appaestlan INSTALLATION WItt BENE: RESIDENCE© COMMERCIAL 13OTHER❑ q ITU INER OF LIVING UMTS- NUMBER OF BEDROOMe: NUMBER OF"APLOYEEB_ CtIARACTER OF 901L TO A DEPTH OF 3 FEET: PtT/SUMP BOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANIUORIFASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION I] SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHINO UNE ❑ NO.6 UNOTH OF LINES DISTANCE TO NEAREBTs WELL FOUNDATION RROPERIY UNE FILTER BED ❑WIDTHS_LENGTH DEPTH DISTANCE TO NEAREST-WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGS RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST-WELL FOUNDATION PTIOPFRTY LME SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL POND$ ❑WIDT11 LENGTH DEPTM DISTANCE TO NEAREST-WELL FOUNDATION PROPERTY LINE I HEREBY CERTBIY THAT I NAVE PREPARED TMS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT INTHE PERFORMANCE OF THE WORK FORWLtKH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN&UCH A MANNER AS TO BECOME SUBJECT TO WOMMAN-9 COMPENSATION tAW8 OF CALIFORNIA.' CONTRACTOR'S MM90 OR SUB-COMRACTWO SIGNATURE CERTIFIES THE FOLLOWINO:'T CERTIFY THAT IN THE PERFO/WIANCE OF THE VVOPK FOR WHICH TWO PEIIMR IS teem,I SHALL EM toY PERSONS SUBJECT TO - WOIKMAN'S COMPENSATION LAWS Or CAUFOR�N.IAa.- THE APPLICANT MUST CAU.24 HOU II IN ADVANCE FOR ALL REOU!RNEO INSPECTIONS. COMPLETE DRAWING BFLOW. SIGNED x C! --"" "'�'r TITLE.. (J.<�'"z�-s' DATE: PLOT RAN tDRAW TO SCAM BCAL.E 'to 1. NAMES OF STREETS OR ROAD&NEAREST TO OR BOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,MTN DIMENSIONS AND NORTH DIRECTION. E%PANIMON OF SEWAGE DISPOSAL SYSTEMS. 3. DRALNSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS MRTWN RADIUB OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED MEAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY• r : . I . . .44 aril. .O . ... . ... .. ... ... .. ..... .... ..... . Codi'/ems♦, '. _ Jf 7 1 ARIL i,i ; ' AHlJ N4URPIfr'' s'iJI3t1C N aFIiVECES �NVIiiQNR�1F +F 1lTla rliVlr I .w.-.=.. .s.em.......,...v".^.{`... EFAYMLNT.LEE ONLY�.,�-`_..-r— -- -,.-:,...� i�-T„."�•�.r- •"+�' ` 1 APRIC AT ION ACCEPTED&Y BATF: ARF-A: TANK,PIT OR BUMP MBI'ECTIOH BY DATE FINAL INSF'ECTlQN BY DATF�1 �] ADD"ZONAL COMMENTS: -�'I}`CJ ! h-A �p•.-p i ACCOUNTING ONLY•. AIDS FAC- PE CODE FEE INFO AMOUNT REM!ITED ItEC /CASH ITEC BY DATE SR I 18 HAT NUTABER INVOICE/ {I k Pv4.Health Serv.•Errviro,174(3196) 2