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APPLICATION FOR LlaUID WASTE PERMIT ;,,AN JOAQUIN COUNTY PUBLIC HEALTh -r- ENVIRONMENTAL ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIIT EXPIRES 1 YEAR FROM GATE(SSU 0 ' (Complsts In Triplissts) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN - JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11110.3 AND THE 8TANOARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. i JOB ADDRESWOR APN# 7"9'y /T �` _ _ crry LOT SIZE,40 --- �pp /vu1 �s ADDRESS �Aia_� PHONE A/ OWNER'S NAME LI LI) CONTRACTOR /_--'l'� r �T ., - ADDRESS �?( / ISI .., .UCL ly YS PHONE�i62� T O— PHONE SUB CONTRACTOR ADDRESS LIC# TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPANIJADDIT10N DESTRUCTION❑ WO SEPTIC SYSTEM PERMITTED LF F'tOBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI+T I 1 HOW MANY APPOmdon# ` INSTALLATION WILL SERVE: RESIDENCE La COMMERCIAL ❑ OTHER ❑ NUMBER OF WINO UMTS: I NUMBER OF BEDROOMS:• ' - NUMBER OF EMPLOYEES: CHARACTER OF BOIL TO A DEPTH OFtt��3FEET. PITIBUMP SOIL CHARACTER: WATER TABLE DEPTH. SEPTIC TANKIGREASE TRAP BTYPFJMFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION© SSIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) .L_i LEACHING LINE GA-NO.h LENGTH OF LINER Uful 6UI�fC 019TANCE TO NEARESTI WELL��FOUNDATION �iCl r PROPERTY LINE FILTER BED ❑WIOTI- LENGTH Y DEPTH DISTANCE TO NEAREST'WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST-WELL FOUNDATION PROPERTY LINE SEEPAGE NTS RDEPTHSIZE�� NUMBER DISTANCE TO NEAREST.WELL UI 0 —FOUNDATION "'�S' PROPERLY LINE Vit ,t BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULER AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR UCENSED AGENT'S OIGNATURE CERTIFIES THE FOLLOWING:'I CERT'IFYTHAT INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN OUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'@ COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB•CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO . WORKMAN'S COMPENSATION LAWS OF CALIFORMA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REn1ARED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X _TITLE: C_!3' DATE: 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, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAY8,AND WALKS, THE PROPERTY OR ADJOINING PROPERTY. yr .. _.. :. ... .......: ............ J..... .. .. . s .. ..,... . ' - ., , - - - ...... .. h 7.... - .. Nr - .. NN ...._'. .. ... ... ... ... ....., .................... � tC .. ... JUL .. -...,.., . .., _ .. .. .. yAS I','e '4r - + . :...... ...:..... �.i�fLl4%HEAhCti LUIS T h l �rar�E_ Ax '©nils . .. . . ....:. .. .. .... ...0 .a. .:. .. ... .. rpt . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: .�/ AREA: TANK,PIT OR BUMP INSPECTION BY DATE ! ! FINAL INSPECTION BY ZJ PATE ADDITIONAL COMMENTS: j ACCOUNTING ONLY: AID# FACT! PE CODE FEE INFO AMOUNT REMITTED CHEC ASH RECEIVED BY DATE OR I PERMIT NUMBER INVOICE R Pub.Health Serv.-ERvir0,174(3196)