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� rC. AAPPLICATION FOR LIQUID WASTE PERMIT N JOAQUIN COUNTY PUBLIC HEALThroERVICESt ENVIRONMENTAL HEALTH DIVISION ��P-flc 304 EAST WEBER AVENUE, STOCKTON, C 2 (209)458-3420 NDN•AfFUMDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MemplBte In Triplicate) APPLICATION IS HEREBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMITTO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS S MADE IN COMPLIANCE WITH SAN JOAOUIN.COUNTY DEVELO)P�MEN�T7TITLE,CHAPTER 8.1110^.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIIp HEALTH DIVISION. JOB ADDRESSOR APN' y3 2, - `f s�C 1 0 l� ��i(1J`l� C � -_- ._CITY 5 '1 p LOT SIZE ^ OWNER'S NAME t�� Jr v � ADDRESS�.:K_f'7/? 7 /}� _��'r✓T'1 � G'�-Ci�PHONE b 7 - R ,,� !/ - CONTRACTOR CJ W r-e Ye ,ADDRESS LIC/' ,PHONE SUB CONTRACTOR ADORES$ -y LICE -PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITJON D DESTRUCTION IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDINO.1 PmC T1•c$TIol I 1 NOW MANY App"40n 0 r ti INSTALLATION WILL SUAVE: RESIDENCE❑ COMMIRCIAL❑ OTHER M NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISOM0 SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP (3 TYPEIMFO CAPACITY NO.COMPARTVENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM( I LEACHING UNE ❑ NO.K LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION_PROPERTY LINE 'L ' FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION^PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION_PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS D IMDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION.PROPERTY LINE DISPOSAL.PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATIONPROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY IOINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 13 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS QP CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:M CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSWED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OFCALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RRECL%RED INSPECTION$. CC44M TE DRAWING BELOW. (y �- SIGNED X� C�T 44�- _ _TITLE: Vl/" 1�1.X- _DATE: '. PS PLOT PLAN IDRAW TO SCALE)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 ENSIONB AND NORTH bIRECTION. EXPANSION OF SEWAGE 13I6POSAL SYSTEMS. 3, DIMENSIONED O ION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS IM'"41N RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING CD _ ATIOS,DRIVEWAYS,AND WALKS THE PROPERTY OR ADJOtWNG PROPERTY. ...;.., .. ., ...., .. Pl)BL1HA4 111� ita .. ... ........ plltlSiQi+t i NVIfiONt�ll�ri9 AL M +TH . .. .... � �� r .... 1� .. . .. .. --�. ... LC.TH Ca"fl1W SAN a AY. Pl,lEil:i 6{�A ...... ..:.. ...,... ' ... Gfu � t � /;•-�� FOR DEPARTMENT USE ONLY �r-y APPLICATION ACCEPTED BY 1._:x11' DATE: �+- AREA: _ TANK.PIT OR SUMP INSPECTION BY DATE I _I. _FINAL INSPECTION BY DATE I I ADDITIONAL COMMENTS: _ T ACCOUNTING ONLY: AID( FAC# - PE CODE FEE INFO AMOUNT REMITTED KI H RECEIVED BY DATE on I PERMIT HUMBER INVOICE J J-4 �7 a 1 - �' Pub.HoWth Serv,-Enviro.174(3/96)