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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH b=RVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complolo in TrIplinto) APPLICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPM'E''N)T TITLE,C AFTER 9-1110.3 AND THE STANDARDS OF SAN.J Ulm COUNTY UC HEALTH SERVICES.ENVIRONME AL HEALTH DIVISION. JOB ADDRE88hTRAPN,In•` J\5 417 Y" � � CITY ✓Lr LOT SIZE• w"- OWNER'S NAME�'fC/��'yt' 'its 5WlPHONE CONTRACTOR_r" _ _5L,R� ^TADDRE6�Z + :7 I - �f"�LICI PHONE SUB CONTRACTOR AODRESS UCN PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF SUI NGJ PESC TENTId S 1 HOW MANY AppSaidon J INSTALLATION WILL 013iVE: RESIDENCE❑ COMMERCIAL OTHER 13NUMBER OF LIVING UNITS: NUMREt OF BEDROOM NUMBER OF SMPLO,l��,,yy Y.EFA::. a + CHARACTER OF SOIL TO A DEPTH OF 3 FEET ,* PITISUMP SOIL CHARACTER.� ,CA-4 WATER TABLE DEPTH SEPTIC TANKMREASE TRAP I]TYPElMpo CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE SIFT STATION D SIZE TYPE OF PUMP �f�c, SAND OIL SEPARATOR(ENCLOSED BYSTEMI LEACHING LINE NO.B LENGTH OF ONES„-j`+G �f /I-C DISTANCE TO NEAREST:WELL FOUNDATN)H /� j PwPERTY LINE FILTER RED ❑WIDTH - LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNET_ SEEPAGE PITS �DEPTH 2��SIZE NUMBER C� ---DISTANCE TO NEAREST:WELLWy _FOUNDATION In � PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LME � I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER ORUCEN ED AGENT'S SIGNATURE CEWIFIES THE FOLLOWING:'I CERTIFY THAT INT14E KAFOR MANCE OF THE WOPK FORWHICH THIS PE ISSUED,I BHA NOT EMPL Y PERSON IN SUCH A M NER AS TO BECOME SUBJECT TO WORKMAN-8 COMPENSATION LAWS Of CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTkRACTWO SIGNAT RE ERTIFIES FO WING,' IFY PETiFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOIKM a Cp S LA O C RNIA, THE C T MU T CALL 24 HOURS IN ADVANCE FOR ALL REGU INSPECTION$. COMPLETE DRAWING BELOW. SIGNED% � TITLE: DATE: �� - --� �s PLOT PIAN{DRAW TO SCALES 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 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 MEAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, THE PROPERTY OR ADJOINING PROPERTY. _ ... - - - - ...., . .. D.- _ _ NT s' ... ? �- I S�iJ JL7A{�L-H§ERV $C HEAL . , NVNOPL E I.Tr.DlViSiQ .;. .. :..- .. .. . ... .... . . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE. AREA: $ TANK,PIT OR SUMP INSPECTION H7 25 Y DATE C'� 1 FINAL INSPECTION BY PATE V i i ADDITIONAL COMMENTS:r_ ACCOUNTING ONLY: ATOM FACA i I PE CODE FEE INFO AMOUNT PEMIITED ITEC CASH RECEIVED BY DATE SR!PERMIT NUMBER INVOICE F I 2 ICaLoD i Pub.Health Serv.-Enviro.174(3196)