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APPLICATION FOR LIQUID WASTE PERMIT --- N JOAQUIN COUNTY PUBLIC HEALTFT.wiERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 A, y;O L�y-I /1 � NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION IR HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWORlats In IIINSTALL THE WDRK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOP/M,FW TITLE,CHAPTER 9-1110.3 AND TILE STANDARDS OF SAN JOAOIAN]COUNTY PUBLIC HEALTH SFIT"CFB,FNVInONMENTAL HEALTH DIVIRION. JOB ADDRF ROM"APN/_ �{ )D "_'�W\� CRY 1��f LOT SIIF OWNER'S NAME /V �1 , 1 J• nnnnf Av� I H -"c CJAI,40 U `/ O ) f 1 CONTRACTOR ADf)nFF6 11C� PHONE RUB CONTRACTOR ADDRFRS UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RFPAIn/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PIISLIC SEWER IS AVAILABLE WITHIN 200 FFFt OF BUII MNO.I PFRC TEST1.1 f I HOW MANY APPll—d— INSTALLATION Wlll SERVE: RESIDENCE 11COMMETTCIAL`IRK / OiHFn ❑ NUMBER OF LIVING UMTS: Nl1MSM OF■FOROOMS NUMNF A OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/RUMP ROIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OTIFA6E TRAP ❑TYPFIMFn CAPACITY NO.COMPAFTTMFNTIt PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ 511E TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACHING UNE ❑ NO.A LENGTH OF LINER DISTANCE TO NEARE9T1 WELL. FOUNOATION PIIOPFRTY UNE __ FILTER SFD ❑WIDTH IFNGTII DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE-- SEEPAGE NE _SEEPAGE PI76 ❑DEPTH SIZE NUMBER MST ANCE TO NEAREST:WELL FOUNDATION PROPERTY tINE SUMPS ❑WiOTII LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WN)TH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROFFRTY UNE I HERESY CERTIFY THAT 1 HAVE PREPARED THIS AMICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND MITER AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AOENT'R SIGNATURE CERTIFIE8 THE FOLLOWING:'1 CERTIFYTHAT IN TILE FERFORMVINCE OF THE WORK FOn WHICH THIS PE RUFF 19 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALTFORNIA.' CONTRACTOR'S HI UNG OR RUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PFRFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJFCT TO WORKMAN'S CO N ATION LAWS OF CALIFORNIA.' T7AANT MUST CALL 24 HOURS IN ADVANCE FOA ALL REOUIRFD INSPECTION$. COMPLETE D11AWINO SFLOW. SIGNED X �� ' �/ PLOT MN(D O SCALE)SCALE •to 1 NAMES OF STFIEFTS OR ROADS NEAREST TO OR BOUNOINO TILE STY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On P110POSFD 2 OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DME ION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J DIMENSIONED OUTLINES AND LOCATION OF All EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNORFO FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. .... ... .._.. ..._ . . ..�. .. : .... SIF I 14 .. .. ►�` c! rI, n: . \ l� FOR O APTMI T USE ONLY� 2- APR'LICATION ACCEPTED BY\ Ka,'�Y�(� ti� � DATE: 12 A f ARFA• gyp . TANK.Mf OR RUMP INSPECTION BY ATF ! / FINAL INSPECTION BV J' j (DATE 1- /) � ADIXTIONAL COMMENTS; (G -� r J/ i Q I /J /lam[!'�G•��e l C"� �� ACCOUNTING ONLY: AIDS RACi ` PE CODE FEE INFO AMOUNT ROM TED CIIEC ASH RECEIVED SY DATE SII/PIEF"T NUMBER IN ewell0 (f 1P131306 5b-4 19 q Pub Health Sere Enviro. 174(3/96) .'," �: .•. / ( / /J� (/A!l�'( .�/1/V' u.GT-tE.lX.lq. , ffF�+ - G A a