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s S "PPLICATION FOR UQUlD WASTE PERMIT M`r iv1; 1 v i SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION OCT 1 6 2000 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 SAN JOA rJ u LIC F� 5 NOR-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED VIF JWEf�T (CBmpkta In Triplicate) f APPLICATION i8 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH 8AN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNll_2Z,2a 4 CRY eRb LOT SIZE eei M— OWNER'S NAME_Zaj21g_-rl/.�5s/.I//ii _ ,,,,_ ,ADDRESS JJ PHONE 2;i ljYJ q GCL7C CONTRACTOR AbbC RESs / fi LICK_ �SYC�fJS` PHONE-?C 1"y Z�Z7 SUB CONTRACTOR ADDRESS LIC• PHONE TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIRIADDITKIN ®. DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.I PEFIC TEBTI*I I I HOW MANY r9 Applleedon l INSTALLATION WILL SERVE. RESIDENCE% COMMERCIAL ❑ OTHER❑ NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS:- NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO ADEPT"OF 3 FEET: PTISUMP SOIL CHARACTER:_ WATER TABLE DEPTH SEPTIC TANKIGAEASE TRAP ❑TYPElMFG CAPACITY NO.COMPARTMENTS - PKG TREATMENT PLANT ELI DIS TANCE TO NEME6T: WELL FOUNDATION PROPERTY LINE LIFT STATION E] SIZE TYPE OF PUMP r SAND OIL SEPARATOR(ENCLOSED BYSTEMI LEACNN6 UNE GGA NO.Jt LENGTH OF LINES_- �.[A-L-DISTANCE TO NEAREST:WELL 7C2 • FOUNDATION PROPERTY LINE_�CI FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL —FOUNDATION PROPERTY LINE rrrr11 r SEEPAGE PIT6 19 DEPTH S SIZE C>''` NUMBER�W D(S'TANCE TO NEAREBT:WELL,J rS ' FOUNDATION y[S PROPERTY LINE SUMPS 0 IIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ©WIDTH -LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I 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 CAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTTFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES'THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CAU.24 HOURS IN ADVANCE FOR ALL REGLSRED INSPECTIONS. COMPLETE DRAWING BELOW. , BIGNEO ��_��// TITLE: i� ,caCiL�� „^ OATE:f t'f.�_ . . PLOT PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST YO OR SOUNDING THE PROPERTY. _ S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSES •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.WALK& THE PROPERTY OR ADJOINING PROPERTY. ..... . ......... ............ .....:....... ....... .........:. .: ., .. .. .. .. .. >,. .. ....., ... - ., -,....... - - I .. ., .. ...... ! ..... r ....... .......... ..:...................... ...,....,,.,...,..........,......... .. .. -- .. ........ ... ..... ..., _,.. .. .. .. .. --1 :.. -- ... .... .. _ i- ...:,. .. .. .., .... ... .. .. W�t 15 .. .. :.., i. r - ` - .. ,.....I :.. ....:....... ......... ..... + x . .... ,.... .... .. .. y . . . . .. :,... .... .... .,.... ... < -� / FO DEPARTM ONLY r APPLICATION ACCEPTED BY DATE: viwob AREA: TANK,PIT OR SUMP INSPECTION BY DATE ! ! FINAL INSPECTION BY DATE/0 6 v - ADDITIONAL COMMENTS: t7 ACCOUNTING ONLY: AID!' FACS PE CODE FEE INFO AMOUNT REINA ITED GHECK46gH:> RECEIVED BY DATE an I PEI4MIT NUMB -INVOICE f Pub.Health Serv.-Enviro.174(3/96) l