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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 962010388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TRU,CH 1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE55/O//R��'1PNI CRY LOT SIZE_ OWNER'S NAML/ �-/-F�I p� ADDRESS r PHONEIFU CONTRACTOIL`- •J-� E� -ADDRESS ` PHONE�C/J�"��7-3 SUBCONTRACTOR ADDRESS LIC/ RHONE TYPE OF SEPTIC WORK: NEW INSTALLATION IrY' REPAIMADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 300 FEET OF BUILDING.) PFAC TEATW I I HOW MANY �/ ApdiaeUon J INSTALLATION WILL SERVE: RESIDENCE 11 COMMERCIAL CJ OTHER 11 NUMBER OF"NO UNITS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOILTO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKJOAEASE TRAP ❑TVPE M. OIJC�TE CAPACITY NO.COMPARTMENTS PILO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑�S1I�ZE TYPE OF'fI}IMP /�/� SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE IQ NO.a LENGTH OF ONES ^W�ILe IOU DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE O FILTER BEV 13 MOTH LENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION W10PERTY LINE [� SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION %OPERTY UNE 1 NEPEBY CERTIFY AT HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE GONE IN ACCORDANCE WRN SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANDREGUUTION O THE BAN JOAQUIN COUNTY.HOME OWNER ORLXIENSED AGENT'S SIGNATURE CERTIFIESTHE FOLLOWING:'I CERTIFYTHAT INTHE PERFORMANCE OF THEWOM FORWHICH THIS PERMITIS IB E I SHALL NOT EMPLOY ANV N IN SUCH A MANNER AS TO BECOME SUBJECTTO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR' HIRING OR SU&CONTRACT) , NATURE CERTIFlES TME F NG:'I CERTIFY THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS BJECT TO WORRM PE ON LAWS OF CALL .' THE APPLICANT MUST CA URS IN ADVANCE FOR ALL LT�REBURIED INSPECTIONS. COMPLETE DRA"N�OBEL SIGN X TITLL:1/ 1 DATE: L PRA PIAN(VFL _-SCALER SCALE 'to S O UNDP THE PROPS 0. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 1. NAM 3. OUTUNE OF THE PROPERTY.WITH DIMEN 1. AND NH N. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF NI AND ROPOSEO STRUCTURES, 6. 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. V Tk.4>,ISFEYL S"(/�j101�I o r MRIurEr1A � - _ PAYMENT SEP - 1995 _._ SAN'JOAO- N COU v I ) -... . - PUBLICHEAL HSEA —"Ill IAL EALTHDI'✓ISiOf: FOR DEPARTMENT USE ONLY q ClL APPLICATION ACCEPTED BY �l \11H....li✓C DATE: I 1 - O- Ci A11EA: A�I �M TANK,RT OR SUMP INSPECTIOO DATE / I FINAL INSPECTION DATE ADDRONAL COMMENTS: b RO]AFS «j �r.L Lo T.LG`'Z-i' L IE' ACCOUNTING ONLY: AIOJ FACJ PECODE FEENFO AMOUNTREMITTFD OHEC ASH I RECEVEDBY DATE BR/PFRMITNIIMSER INVOICE z z5 a5b.�o 114p4 Ub q -7 1 5 a