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APPLICATION FOR LIQUID WASTE PERMIT —A JOAQUIN COUNTY PUBLIC HEALTH _®RVICES r ENVIRONMENTAL HEALTH DIVISION SEPTI V��e 304 EAST WEBER AVENUE, STOCKTON, CA 95202 S (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompl/to In TFgUelbl APPLICATION IB HEREBY MADE TO THE SAN JOAMIN COUNTY POR A PERMIT TO CONSTRUCT ANDAOR INSTALL THE MAK DESCRIBED, THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVEL PM TRIS.C AFTER 81110.0 AND THE STAIJDRDS OF BAN JOAOUIN C ULT'PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH OINSION. G )TH [ CTLOT 812E JOB ADDRE68/O ��ZT ADDRESS71 OWNER'BN TZ CONTRACTO ADDRE6B oNA66 rrn 11 07 SUBCONTRACTOR ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIDADOITION DESTRUCTION ❑ IND SEPTIC SYSTEM RRMITTM IF PUBLIC SEWER 18 AVAILABLE WNHIN ZOO FEET OF BUILDING.) pERC,TESTI.)L i HOW MANY ApptleEtlen i INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL)( OTHER ❑ NUMBER OF LIVING UMTS:$ NUMBER'OF//S��ED,,RIOIyO'M�S:� NLMB61 OF EMPLOYEE): CHARACTER OF SOIL TO A DEPTH OF..��O((FEET:—]I-1 N l) MIBUMP SOIL CHAR)U TER, WATER TABLE DEPTH SEPTIC TANKPOIIFASE TRAP Z YYPG/LIF CAPACT' + l� I / NO.COMPARTMENTS WO TTIFATMENT PLANT❑ DISTANCE TO NEA#UIT: WELJZCJ� FOUNDATION PROPERTY UNE UFT STATION❑ 612E TYPE OF PUMP SAND OIL SEPARATOR IENCLOSM SYSTEM) L"CM:E � ES DISTANCE TO NEAREST'WELL FOUNDATION PROPERTy MINE FILTELD / ;AxWHTLENGTH DEPTH MMCE TO NEAS :WFOVNDATON -M KV UNE I MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEVAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SLMPS [3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THESAN"AMIN COUNTY.HOME OWNEROR LICENSED AGENT'S SIGNATURE CERTIFIES THE POLLOMNG:'I CERTIFYTHAT W THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMA/N'S COMPENSATION LAWS OOF�111CALMORNIA.- THE APPLICANT MUST CALL ZS HOURS IN ADVANCE PORAALLL RE�Q�UIIR/EED��INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED K 1 Y/1 D l A l 11 /1 V' TIT �P "�NVLL_l DATE9 4 `�ITp•v�-�v1 ROT PLAN DRAW TO SCALE)SCALE— 'IG 1. NAMES OF STREETS OR WADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RAIN11S OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED MEAS SUCH AS PATIOS,DRIVEWAYS) j� DRIVEWAYS.AND AANNDWAIXS. THE PROPERTY OR ADJOINING PROPERTY. ifM RMP,VA40J1+oRFira vnl.c I t "T 2/� �J\ t�^L � XJEX] OIifDCCx-{4Gu �,- � �•� .... 0 1/'�NL WnTr Y[-!LAwM W2 X L - J INT LIFT 9Ti.TgJ O T z o VIA `lJ0 Q D t `. cy.HGRA 1 _.._ \ I .VIP A_ -- i; \ Q APPLICATION ACCEPTED BY I r�f/ 4.� GATE �� ✓ AREA TANK,RT OR BUMP INSPECTION BY DATE / / FINAL INSPECTION BY rjj/ ATE / (•� ,ADDIT)ANAI�OMMws: AT d/hT/ kd "e y� GGIC! -�7 ACCOUNTING ONLY: AID/ FACT PE CODE FEEINFO NMOUNTREMIITEO ITEC CA6H RECER,wly DATE N/PDWIIT NUMBER INVOICE/ Pub.Health Sere -Enviro. 174(3/96)