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fAPPLICATION FOR LIQUID WASTE PERMIT SAN-aOAQUIN COUNTY PUBLIC HEALTH SEh4ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)466-3420 NON-REFUNDABLE PERMIT EXPIRES 1_YEAR-FROM DATE ISSUED (Complete In TrlpSeatel APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMErt TITLE,CHAPTER/8.11 10.33 AN/DJ THE HT OF SAN JOA N COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. J / JOB ADDRESSOWlterll'IWA # �/ & s 46 . � C•ITY / '?1_5-74o, LOT 9RYD �3 OWNER'S NAME / PHONE 4? r f CONTRACTOR -. S ADDRESS LION PHONE SUBCONTRACTOR ADDRESS PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D DESTRUCTION ING SEPTIC SYSTEM PERMITT EO IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.( P TESTIs 1 NOW MANY INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL OTHER 13 NUMBER OF LIVING UMTS: NUMBER OF BEDROOM$: NUMNI R OF EMPLOYEES: I CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SON.CHARACTER: WATER TABLE DEPTH SEPTIC TANKlOHEASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS RIO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OR SEPARATOR IENCL OSED SYSTEM LEACHING UNE ❑ NO,o LENGTH OF LME$ DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER NED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑MUTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE BEEPAOE RTS ❑DEPTH BRE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WROTH LEMYM DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS (3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES q ANDREOULAMNBOFTH!9MJOAOLANCOUNTY,HOMEOWNERORLICENSEDAGENT'BSIGNATURECERTIFIESTHEFOLLOWING:'ICERTIFYTHATMTHEPERFORMANCEOFTHEWORKFORWHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORMA.' CONTRACTOR'S HIRING OR BUB-cONTRACTING smNATUCERTIFIEB THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,4 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSAt W8 OF C RMA.' T APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOLMAD INSPECTIONS. COMPLETE ORAWINO IGBELOW. SIGNED X TITLE: DATE: G PLOT PLAN tDRAW TO SCALER SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNPINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE OI8POM SYSTEMS. 3. DIMENSIONED OUTUNES 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,DRVEWAYB,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. _ - ... ..,. .. .. - bv ., . : ...... :..:. I :.: . .., ,. ............ ............, � r . .. ..... ,. .. .� . .. ... ...... I - - .. SSy f. 7 .................... ......... ...... ... .. ....... ......... _ ........ . : :: : .. .�Uf�1IL i : Y1i k ridl�; . �NVIP�NPJf�NT-�t t3r Ak't ti�i�llfalUiu . ...... . .... . ... .. . .: - FOR DEPARTMENT UBE ONLY ... -�gf L 1 U' 1111 APPLICATION ACCEPTED BY ©'�' DATE: �� /,� ,.,.-_,AREA: TANK,PIT OR BUMP NSPECTIq1H BY DATE I - FINAL INSPECTION BY DATE '/ ADDITIONAL COMMENTS: ACCOUNTING ONLY: Aro# FAC# PE CODE FEE INFO AMOUNT RUNITEO 1 ABH RECEIVED BY DATE OR!PERMIT NUMBER INVOICE# V z s^ -7 (boa 3/E I �l Pub.HsaM Serv.-Ermiro.174(3/96)