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• � f APPLICATI0111 F011 LIQUID WASTE PERMIT • a4 SIAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CBmphts in Triplints) APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION t9 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. AC-4- JOB ADDRESS/OR AP�NlN S �: dt G IIA=j A Ci CLOT SIZE,`0 I OWNER'S NAME 1� �1,(I� S.hI �I _ ADDRESS ac44%l /- PHONE, ~ 1� CONTRACTOR V V 11' '^W ADDRESS o L LIC/{APHONES ' J SUB CONTRACTOR ADDRESS —UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION, RE+AIRIADOITION ❑ DESTRUCTION❑ MO SEPTIC SYSTEM PERMITTED If PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDINO.1 PE RO TESTIN 1 1 NOW MANY ,' Appge�tlen# INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALS OTHER❑ NUMBER OF LIVING UMTS: NUMBER 4F BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OFF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH EPTRAP 101YPEIMFO CAPACITY— eI'ZS _ _no.COMPARTMENTS„�� -- PKI TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE 0 LIFT STATION 13SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEMA t �6 LEACHING UNE P NO.B LENGTH OF UNES f DISTANCE TO NEAREST:WELL�rFOUNOATION i b —PROPERTY UNE Eftm FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST-WELL FOUNDATION PROPERTY UNE MOUNDED - ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WEU. FOUNDATION PROPERTY LINE SEEPAGE PNTS ❑DEPTH SIZE NUMBER INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIVE BUMPS (3 WIDTH LENGTH DEPTH ONSTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS 13 WIDTH LENGTH DEPTk DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOIK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CEFMFYTHAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER As TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOA NIA.' CONTRACTOR'S HIRING OR BUS•CONTRACTING BIONATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMTT 15 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 74 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWINrG BELOW. SIGNED% TITLE-. L.b G DATE: L� PLOT PUN{DRAW TO SCALE)SCALE •to I. NAMES Of STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAOE 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, 6. LOCATION Of WELLS WITHIN RADRIS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS_SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOIMNG'PROPERTY. ....... .:. ...,. :.. .., - .. :., - . .4 .. ... . .�� «s .. �.. Q QkIA � u ..... ........: ... *. ... �s �.. .. lip O*df t d b cc ...... .��.. �... �._ �... Ovl aY . ^. ..�:....,^._.l.l..�.nb :�...�.. :tDDU o }} ........ _ 1 ............. ... .: _,... ......:.............. ............:.......:.................. �� -- FOR DEPARTMENT DISE ONLY GJ �/� V y Ir APPLICATION ACCEPTED BY DATE: r AREA- C TANK.PIT OR SUMP INSPECTION BY DATE FINAL INS CTION BY DATE ADDITIONAL COMMENTS:� •� !~r _ ACCOUNTING ONLY: AID# G FLAG - PE CODE FEE INFO AMOUNT RIMITED CIMC ICA N REC BY DATE SR I Pt3W87 NUMBER INVOICE f 2t t� Z 5' 2 75 Pub.Health Serv,-ErnrirR.174(3196) 4