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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 1209) 498.3420 MS - 98 - t6 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 18 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 SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER ft'-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# Z I 7-S0C- L l-j [ �,, �r[ CITY I� f i C-A LOT SIZE'/'/ /q -AC/ OWNER'S NAME NA,.,Ic` �N�G�.�...r > ADDRESS Z12SQ [:. w �l" I�e� Lel (-CZ-0,1 C A PHONE ONTRACTOR_ I--r U- All b�� ' 2 Rc..C�Q(oi� FJ I r It SS ADDRESS_ Z �1�v1�S,hy.-�(ryl7� LIC! R10NE 3�T- 37y1 �UB CONTRACTOR_-SC-OS+-J S iNt-7V�7C AIC'uL�[LMIDDRFSS•?i I t4, rE/LS'f4• A C ST/cTl••j UC! PHONE TYPE OF SFPTIC WORK! NEW INSTALLATIO RFPANVADIATION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEINER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TFSTIO f�I NOW MANY INSTALLATION ''1 INt TALLATION WILL SERVE: RE61Df.NCCOMMERC1Al ❑ OTHER ❑ 102r NUMBER OF LIVING UNITS:— NUM19[OF BEDROOMS: NUMBER OF EMPLOYEE!: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PT/BUMP BOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.•LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENOT14 DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PIT$ ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RUt FS AND REOULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WIRICH THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION WS OF CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW). SIGNED X - TITLE: �(�f••!V]CC IZ DATC9 11 PLOT PLAN(DRAW 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 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 AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. VICINITY MAP .... ,1 _ dEFILEWN RD HONNEY RD ca[U6 ; - PD.auO N 2to54,33 Z -IWWO[td f EI(21T = --- ------ --�---- iert--------------------------------- W _ SEC 13 1� 301 R£l[AINDEIi .-S1 711!3 Aon l } PAACEL 1 - I 4"A— N 3?0� �ANIMEN"i E 70,rly EA� '• ... 1 1 UG PUBLIC HEALTHi, I� }I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: ,ARF/!; l TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID! FAC# PE CODE FEE INFO AMOUNT REMITTEDCHEC /CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE! zz / $