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APPLICATION FOR LIQUID WASTE PERMIT SAXN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED te APPLICATION IS HEREBY MADE T THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRIUCT ANDrORIINSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9stel -1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# r 9 63 <�'(O ';� �J r s!^ PCD CITY C LOT SIZE�Ac OWNER'S NAME _ f' ��I ADDRESS se _C oe G PHONE CONTRACTOR_ ADDRESS /�'`` /l/ LIC/ PHONE SUS CONTRACTOR_ /,/ 1 /`r�� ADDRESS �?y, ?2'(? ��T/Y.CJI)f� LIC/ PHONE TYPE OF SEPTIC WORK: NEW IN6TAlU1TOH REPAIR/ADDITION ❑ DESTRUCTION ❑ r (� (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PB1C TESTI.)( 1 HOW 11MANY 1 APdloetlon INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER [111-� 732 NUMBER OF LIVING UNITS: z-3 11-1 NUMBER OFBEDROOMS: U _�V L NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET:A PC)&3 PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH , 1 SEPTIC TANK/ORF.ASE TRAP ❑TYPE/MFG 24-Z/ CAPACRY_1 /f) ��__NO.COMPARTMENTS PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL ��T FOUNDATION- r PIROPFFTFY LINE r UFT STATION❑ SIZE TYPE OF PUMP SANG OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE NO.6 LENGTH OF ONES //Tf F' T �N/-� I& ✓ //'7' /_'T- _ NCE TO NEAREST:WFLLI4Ip FOUNDATIO N,�_PROPERTY LINE /:--j \ FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE �\ MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMP6 11WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE_ 1 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 RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WIIICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGLARE'D INSPECTIONS. COMPLETE DRAWING BELOW. o 0� SIGNED X t �CJ_ �A�'C-� � TITLE! DATE:_�fy'�� 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. -- --- ID . ►�l�Q. .:_. ........ . AIV G b . Y' C(4 _ s P 1 3 1996) -ENVIRONMENTL HEAT L PERMIT/SEE2VICE5 FOR DEPARTMFNT USE ONLY APPLICATION ACCEPTED BY - DATE: r 2 t � AREA: M TANK, T OR SUMP INSPECTION BY DATE / ( FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: RIO/ FAC# PE CODE FEE INFO AMOUNT REMITTED CHECK/CASH RECEIVED BY DATE 611/PERMIT NUMBFIR INVOICE