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` PLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95 0 n5-- C/ 7 / (209) 468-3420 f ��)� (_ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v ��uuu (Complete In Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/O NSTALL THE WOW DESCRIBED. THIS APPUCATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9. 1 10. ND TH BT/AyDARDS OF SAN JOA COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE88/OR A Q 'G~^� CITY C�(/(/�C- LOT 81ZEA C" OWNER'S NAME ( Cr%CL ADDRESS //� / 7 (PHONE CONTRACTOR ADDRESS/2!y,<- 'W- LIC/ �C G�.J PHONE SUB CONTRACTOR ADDRESS UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AODITIO DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BVILDING.) PERC TESTb)( I HOW MANY Applb.eon I INSTALLATION WILL SERVE: RESIDENC OMMERCIAL ❑ OTHER ❑ NUMBER OF WANG UNITS:\_ N BER F 6 Or Ms'---ra N�gI OF EMPLOYEES: /C}1/A�CT�JA OF SOIL TO A DEPTH OF 3 FEET• (� PrT/SUMP SOIL CHARACTER ATER TABLE DEPTH (LJ:PTIC SICNK/OREASE TRAP ❑TYPE/MFG CAPACITY_ L ZD O NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL_ ( 4— FOUNDATION O I PROPERTY LINE O Z UFT STATION❑ SIZE TYPE OF PUMP j]7 SAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACHINO UNE �10,a LENGTH OF UNEB Zia //1-( DISTANCE TO NEAREST!WELL O fTbUNDATR)N / (/ �S PROPERTY UNE _ FILTER SED 1/0 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH / DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS DEPTH Z SIZE Z NUMBER / DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <7 SUMPS WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I 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 UCENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSONIN H A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:' ERT TIN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENS TION 9 OF CAUFORNIA.- TH ANT MUST CALL 24 HOURS IN ADVANCE FOR A^LL\JREGURED INSPECTIONS. COMPLETE DRAWING SIE/LyOW. SIGN J/+(� - 7- ).7 1v TITLE: 1 DATE: I C/ 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. .... .......... ...:......i.......... ... - ....i.............i.... ... - _.. ...:......................`....... ... - - ;... ....,.. .:..... ..: ]� { ......L..... ............:............;.. .....;............:.. ..... ... /� i ... 1 : 4 ........ . .. . ' �. .��y$ :..... .......:.............:.....: ................ .:...........:.......:......:......: .. .. . . .. ti :.................... .......... .. . .......................................... ..... ...;...........:.... ... . :..... `... ......:........ .............:...............:....... .._ :.......... .. o......... .. ..°.....::.. ............ .........` ...................... .. ................................:.......... .. .. D ... �ts ................-ra,�k u p :......:.................. ;.. .: ;...... ......................,....... ......:.....,. SAN JOAQUIN.COUNTY PUBLIC HEALTH ........ : SERVICES .................... ..... .. ''"'''"'" �.NVI bDMEJTALHEALTH DIVISION ............. .....,.....L....'....... :...... ......:....... .....,....... ..... % DEPARTMENT USE ONLY APPLICATION ACCEPTED R��/' `"--- DA7F / !>,.0 / 6 AP.FA: TANK,PIT OR BUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE / ADDITIONAL COMMENTS: _ � � 491An ✓ �J v ACCOUNTING ONLY: AID# FACSj� PE CODE FEE INFO AMOUNT R IT C TEC /CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE I Pub.Health Serv.-EnvirO.174(3/96)