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APPLICATION FOR LIQUID WASTE PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVICEr' ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 488-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ((CompktB in Triplkat!) APPLICATION 1S HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1110.3 ANMD/THHE STANDARDS ,yO/F SAN �JOOAAOUIN COUNNPUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR�AP�N�/ 73 ✓`� •CLQ[ `�L'�/nom/ 'CC-,LIQ, `�LC/K{/YPLOT SIZ J�� OWNER'S NAME lJAW Q11LT ADDRESS / /SCC / C = a'P /�'+'��/ [�L��/ PHONE W/o/,�y�VC1�(J� CONTRACTOR 9 �!/J�Ci ADDRESS/,7 C• G�LL✓1C'l'l r�I S7'• 7"��`- LIC! ` ` 7��-S'R10NEJ�TC�J-SJ�J SUB CONTRACTOR 7 ADDRESS UCF PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SE R IB AVAILABLE WITHIN 200 FEET OF BUILDING.) PBM TESTI#1 I I NOW MANY APPBwtlon! INSTALLATION WILL SERVE: RESIDENCE 11COMMERCIAL*1 OTHER ❑ NUMBER OF LIVING UMTS: NUMBER OF BEDROOM{: NUMSBI Of B.FPLOYEES: 34) 3-5 CH OF SOIL TO A DEPTH OF 3 FEET: N,�4 PT//')SUMP SOIL CHARACTER: 44. WATER TABLE DEPTH 6I— TA GRSABE TRA( ❑TYPEAMFG CmLC-1[ YaL CAPACITY DO NO.COMPARTMENTS -3-5- cm PLANT❑ DISTANCE TO NEAREST: WELL e`�00�� FOUNDATION !Q � PIOPERTY LINE UFT BTATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) 0 LEACHNO ONE ❑ NO.B LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPFRTY LINE SEEPAGE BTB IlzDEPTH� SIZE (pO �I NUMBERS/-- DISTANCE TO NEAREST:WELL•��/'f FOUNDATION X25 PROPERTY LINE 3Q Y ` SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE C DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE F I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAOUIN COUNTY.HOME OWNER OR ENBEDAGENP3 SIGNATURE CERTIFIES THE fOLLOWINM'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH TNI6 PER ED.18 NOT EMPLOY ANY , NT SON IN BUC A ANNER AB WSIGNTO BECOME SUBJECT TO WOIKMAN'B COMPENSATION UWB OF CALIFORNIA.' COMMCTOR'S HIRING OR r SUB-CQ RACTINO IGH TUR CERTIF TI LLO) NO: 'I CEI THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18186VED,I SHALL EMPLOY PERSONS BVBJECT TO r O AN'B COMPS ON CALIFOfl IIA.' PO NS- WT CALL 24/IOUIIB IN ADVANCE FOR ALL REOUREO INBPFCTONS. COMPLETE DN,WING BFIOW. �• q S ED% PLOT MN(DRAW TO BCALEI SCALE 'le 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE P OPf Y. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS VBTHIN RADIUS Of ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE P()PERTY OR ADJOINING PROPERTY. I L �P. 21 M� i ( � A#'• I D'2Ai- RoR�R _ MAY 211996 00 w �U$LIC HEALTH ES l apo F ^ Sed t -.,Nti VLkNM€ICTAL HEAtT(LTH ri DIV) FOR DEPARTMENT USE ONLY P nWPLIGAA///D'''O��N nCCEPTEtl�� - _ - - - 9 )J DATE: --J -z- I yIy / '�" AREA: G I)�� I'A AN SUMP INSPECTIO/NlBLY J 1 DATE 51 7_ / Mi FINAL INSPECTION BY ! r' � T '-z , DATE 3-1 4 ADDITIONAL C6 ENTS: L?YOLC+T v/�� /2S AG✓ 'L+-tetG-T ��.(�,p ACCOUNTING ON Y: AID# FAC# l PE CODE F AMOUNT REMITTED C EC /CASH RECEIVED BY DATE SRI/PIVRIMIT NUMBER INVOICE! z o L . � d oa72q