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APPLICATION FOR LIOUID WASTE PERMIT WIN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTOiJ, CA 95201388 )209) 4883420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Camplete in Triplicate) APPUCATON IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TET LE.CHAPTER S.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR AM# 2/ 31 06 22;c4-r-1 CRY OL F�yJ� LOT 61]E____ OWNER'S NAME n T�4n/Ir As// ADDRESS e ] ,1 rg PHONE CONTRACTOR p,/C.�J011Eft CJS . ADDRESS_ / p/'V CCLIfGL �jy�/G LICE �EYaT»� RIONE_3 -�39.i" SUB CONTRACTOR I ADDRESS UCI HONE OF TYPEEPSEPTIC WORK: NEW)NEWER IS V ❑ REP200 FEET ROM ❑ DESTRUCTION -- (No SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 100 FEET OF BUILDING.) P91C ifeTl+l I I HOW MANY a INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ J NUMBER OF UV1NG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: .cf CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/ORFAEE TRAP ❑TYPEMFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSEO SYSTEM) LEACHING UNE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINEij FILTER am ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH 812E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS 13 WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPEREI'UNE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE"FOL WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH T141S PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMFENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING On SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIPYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WOWMANNN''SS C'OMPE ATION LAWS Of CC//A]LIFOIWIA.' THE APPICANT MUST CALL 14 HOURS IN ADVANCE FOR ALL REOURM INSPECIWNL COMPLETE DMWING BROW. SIGNED I/ _J(//0� TRL E V 'V✓I' ` DATE:�� 10, POT PAN(DRAW TO SCALE)SCALE—'40 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. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PTOPOSED STRUCTURES, E. LOCATION OF WELLS WITHIN RADIUS OF ONE HVNDEIEO FIFTY IT.ON INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. (✓h �n 4rrs�r! ��cEr�/� PA s MENY DEP 12 1996 "F ERVICES ., -U_TN Di" Sil lnl /L �)-,� FOR DEPARTMENT USE ONLY (1 APRICATION ACCEPTED BY_�yK�`Cy{ W DATE! — ^ AREA:_ TANK,PT DR SUMP INSPECTION BY DATE_I I rINAI.INSPECTION BY DATE /0 r If f ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDE PACO PE CODE FEE INFO AMOUNT REMITTED HEC E/CASH RECEVED BY DATE M/PERMIT NUMBER INVOICE F s- a - d- q 7 :3 6 s' 'P3