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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTI:�-.JERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11100.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR AP�NI �`1-r1FnG✓,•�/,+-`•r y �C'CMZ.i- ry ) p G -f CITY I n�--�-Ty N ry LOOT 81ZE -7�.+�I��`J OWNER'S NAME *p V C•'F'IV�p�V`V1 V�V1t ADDRESS W f�I�t/ I pV• .�1�y(�`��] ,;�r +� PHONE "t Iy � `ry7 CONTRACTOR MCLDo oT,L-V -f S Vy�T ADDRESS 'AlU'47 01:L V rt✓1 R L—V L1CI J PHONE`6 04 ` SUBCONTRACTOR ADDRESS UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIS)I I NOW MANY �^ Appllo�tlon l INSTALLATION WILL SERVE: RESIDENCE I@ COMMERCIAL❑ OTHER 91 LB l F 1:C G Cz NUMBER OF LMNO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: �[yy,� ��;�'�' CHARACTER OF SOIL TOA DEPTH OF 3 FEET: CLAN ? P f PIT/SUMP SOIL CHARACTER: L-� A ")PIWWATER TABLE DEPTH , 1� SEPTIC TANK/GREASE TRAP ❑TYPEIMFG CAPACITY NO.COMPARTMENTS \v PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) 2 LEACHING UNE 21 NO.6 LENGTH OF LINES I'- 40*' DISTANCE TO NEAREST:WELL FOUNDATION I � PROPERTY LINE JEST-reS FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ('1. MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 2 " SEEPAGE ATS 19 DEPTH �7 Z SIZE 6" NUMBER _DISTANCE TO NEAREST:WELL I0 C"3 FOUNDATION IOC, PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE , DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 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 OWNEROR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT INTHE 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 CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAAUFFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR AREQUIRED REQUIREINSPECTIONS. COMPLETE DRAWING BELOW. n� SIGNED X �`�'`�' TITLE: co-wy'-6`-C- U 2— DATE: C��Ct 0 PLOT PAN(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 RADIUB OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DW VEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. Kz.�. ... . ... ... . . _....;.......;......,....;......:.......:..............;..............> .. .. .............. . _.................. .. .. ....................................... .. .. .. .. .. .......�........... .. ........... ....... ........... .....` .... .. . :....;... R...... ,ram .. ti...... ......... . ELLE. ..;.... ;. tL... �. , ............ .. ..... :: .... :.::::.:..:.:::.:::.... . : ... ..:::::: . ... ........... N N : .. . ..... .. ..... . h ..... ....:........... .... ,.......:.......,.....;......... �.... . : - .. { .... .. i.. .i............:.........................:....... .... f .. :......:............ . ..:......: :.... :......... N.......:..... ......;..............:.....:. ......... .. ... <.�'.. : '.5.. . ........ ......:.. .. .. r7zvl;Wh :.. . :.... . ...:............:...... L N....... . . �. . .......... MAY 2 ... ..... ... ;... :.. . o.....:....... :..... ... ............0.19.9$. E'LSlBLaC M�4LT+hfiffiV E$ .., ) NYIRCINA7ENTAI,HEALTH�i:IV SIOrd APPLICATION ACCEPTED BY DATE: ' L AREA: 0211 TANKT R SUMP INSPECTION BY DATE /Z( FINAL INSPECTION BY DATE !2 I AD DI'I CMMENTS:al�erT ACCOUNTING ONLY: AIDI FACT PE COCE FEE INFO AMOUNT REMITTED CNE IC/CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE I a7 I� �� D G` 393 Pub.Health Serv.-Enviro.174(3/96)