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(�-'1PPL1CATION FOR LIGUID WASTE PERMIT SAN,-wOAOUIN COUNTY PUBLIC HEALTH SE�CES L ENVIRONMENTAL HEALTH DIVISION Ie 384 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 MON-REFUNDABLE PERMITEXPIRES -YEAR FROM DATE ISSUED ICBIDpkin In Triplicate) APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESGIOR APNF r L� CITY F`�� LOT 81ZE iI w OWNER'S NAM C_ ADDRESS ` PHONE � A - CONTRACTOR ADDRESS PHONE [�/�/ SUBCONTRACTOR LK;/ PHONE _i j AV 0',ah, 637 10, TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMTTTEO IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTN ( 1 APPIe�Uen I i INSTALLATION WALL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF 8EDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: / WATER TABLE DEPTH SEMC TANKPAII&ME TRAP ❑TVPEJM .�l�, '* L— _CAPACITY�p.B�©-^y NO.COMPARTMENTS LO RCG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL db J FOUNDATION r� -] PROPERTY LINE„ LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR[ENCLOSED SYSTEM) LEACHING ZINE ❑ No.•LENGTH OF LINER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPr" DISTANCE TO NEAREST:WELL. FOUNDATION PROPERTY LINE SEEPAGE FRB ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE BUMPS I]WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERIY LINE OISPOBAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORD WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE SAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN CO .HOME OWNER OR LICENSED AOENr'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHK:H THIS PERMIT IS 188 H1ALL NOT EMPLO PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOMS WMNG OR MT 610" CERTIFIES T FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TM8 PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO IK I' 6 SA WB IA.' THE APPUC T MVS 24 HOURS IN ADVANCE FOR ALL REGUIRm INSPECITVNB. COMPLETE DRAWING BELOW. 8 NED x TrTLE• �'_ DATE: PLOT PLAN IDRAW TO SCALE)SCALE •to 1. NAMES OF STREETS 8 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 SY8TEM8. 3. DIMENSIONED OVrUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, � S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLU COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKB. 6'4&6'4&p*THE PROPERTY OR ADJOINING PROPERTY. ' . �",� voM 1�e- _..t . . fo©......... .. . .. ; c gv .. .....:.......:..... ^�° .. .. ::: ............ ...: ... ... .. '` : s .. . .. . .� ... A FOR DEPARTMENT 115E ONLY APPLICATION ACCEPTED BY � DATE: AREA: Q Q TANK,PIT OR SUMP INSPECTION BY DATE 7 t FINAL INSPECTION BY DATE C.J Z� 7 A1DDITIONALCOMMENTS:&ZM9 • AcuacT e,+1 1 r+ t K ao ACCOUNTING ONLY: AM FACS �• �Alfc+B�. ei�-LO p PE CODE FEE INFO AMOUNT REWITEO KASH RECEIVED BY DATE SR/PERIOT NUMBER INVOICE 9 Pub.Heakh Serv.-Enviro.174(3196)