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APPLICATION FOR LIDUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 f <br /> OP <br /> (209) 469-3420 [Jj/ <br /> MON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Camplala In Trlplkatal <br /> APPLICATION 1811ERFRY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORE(DESCRIBED. THIS APESICATION IS MADE IN COMPLIANCE WRIT DAN <br /> JOAQUIN COUNTY DEVELOPMEENNT T LE CHAAPPTTEEfl 9-111110�.r/31 AND THE <br /> ]STANO/ARRRUS/OOF BAN JOAQUIN COUNTY PUBLIC HEALTH BERVVIIC�E.B,/ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORES6/OR BPNNI-I�`/ 7� /•// �/- /z //�(yy.�' C l�C //!// - ^ LOT SIZE p� <br /> XOWNED 6 NAM'4 / ��Gl� �/Y/G ODREB�J/ //� �/�/J /JOCK"/G� RIONF`Qy-/ �p- � <br /> CONTRACTOR ADDRESS LACI PHONE <br /> SUB CONTRACTOR ADDRESS LIC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIAODITION ❑ DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC DENVER IB AVAILABLE WITUIN 200 FEET'DOFF BUILDD�INNGG11 PERC TEpb)1 I NOW MANY <br /> INSTALLATION WILL SERVE: RESIDENCE 11COMMERCIAL ❑ OTHERa�///E'/ ®[) <br /> NUMBER OF UVING UMTS: NUMBER OF REOROOM6: NIIMRER OF BAROYEFI: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PR/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANIOGREARE TRAP ❑TYPEWFO CAPACITY NO.COMPARTMENTS <br /> EKG TREATMENT RANT ❑ DISTANCE TO MEANEST: WELL FOUNDATION PGDPERTY UNE <br /> UFT STATION❑ SRF TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACNNO UNE ❑ NO.B LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> FILTER RED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED ❑W1D114 LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE ISTS ❑DEPTH BRE NUMBER DISTANCE TO NEAREST!WELL FOUNDAIUCIN PNORRTY UNE <br /> SUMPS ❑WIDTH LENGTH DEM14 DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL SONGS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION mOPERTY UNE <br /> (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 MILES <br /> ANDBEGUUTIONS OF ESAN JOAOUIN COUNTY.HOMEOWNEROR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'(CERTIfYTNAT IN THE PERFONAANCE OF TME WORK fOR WIUCII <br /> THIS PER <br /> I6188UE ,I IIAIl EMPLOY ANY PERSON IN SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." COMRACTOR'S IIINNO OR <br /> SUB-CONI RACTING ON URE E IFIES THE FOLLOWING: 'i CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOp WIIICN THIS PERMIT ID 198UE0,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COM 6A ON OF CALIFORNIA.• THE APPL1CANi MWT CALL 2A MOUS IM ADVANCE FO/R(/ALL)L/RFOURED IINSP�ECT/I/O//NQS. COMPLETE DRAWING BELOW` <br /> ROT PUN(DRAW TO SCALE)SCALE •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY'. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PRDPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL Irf"EMB. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED BTRUCTUREB, 6, LOCATION OF WELLS WITHIN nAD1US OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> q <br /> I ILAL.. I <br /> - � PJVIFinPJhll F?Ii 4I �: <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY / / ,DATE: I AREA: <br /> LANK,PIT OR SUMP INSFECTION BY DATE / / FI L SPECTI _ BY DATE ( / <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODE FEE INFO RUNT REMITRF.O CITE /CASH I RECMVED BY DATE SA/ <br /> PERMIT NUMBER INVOICE# <br /> S7o O <br /> x'331 (0 <br />