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r S 7 r �APPLICATION FOR LIQUID WASTE PERMIT a SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 so-1101— W .hrd sod) (209)468-3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "A �y� (Eamp�t�1n TtipCNsta1 APPLICATION IS HEREBY MADE TO THl BAMOAaUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/DR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAOWN COUNTY DEWLO TITLE,CHAPTER 9-1110.3 AND TH STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH BERVVICCEEBB.dE'N_VIRONMENTAL HEALTH OPASION. JOB ADDRESSIOR APR# , ell CITY C....l�` '�-'- LOT SIZE OWNER'S NAME d f,'. J12 . ADDRESS PHONE z- c CONTRACTOR ADDRESS/ PHONE G 3 5--3q-? 2 P 1c� t _KI SUB CONTRACTOR ADDRESS LICA PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADWTION DESTRUCTION❑ 810 SEPTIC SYSTEM PEMARTED 1F PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF RUIN PERC TESTI+}I 1 HOW MANY WW ANootim F INSTALLATION WILL SERVE: RrENCE COMME ciAL ❑ OTHER❑ NUMBpI OF LANG UMTS: NUMBER OF IEDROOMB: NUMBER OF EMPLOYEES: : , CHARACTER OF SOIL TO A DEPTH OF]FEET PttlBUMP 601E CH WATER TABLE DEPTH / W SEPTIC TANXIOREASE TRAP ❑1'YPFThIFO CAPACITY NO.COMPARTMENT$ PKO TREATMENT PLANT❑ DISTANCE TO NEARMT: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SI2E TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEMA LEACHING LINE �NO.R LENGTH OF LINES/" ono DISTANCE TO NEAREST:WELL/ +4 FOUNDATION � r PROPERTY LINE lob FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑VWDTH LENGTH'`_ DEPTH DISTANCE TO NEAREST-WELLFOUNDATION PROPERTY LINE SEEPAGE NTS k�E1'TIf�7 � 812E :Ai_.- -NUMBER eQ DISTANCE TO NEAREST:,WELi�FOUNDATR3N�PROPERTY LINE�d� •'�� SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HERESY CERTIFY THAT I HA PARED THIS APPLICA AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE I'"JO NCOUNTY."OR ORLICENSEDAGENT'S SIGNATURE CERTIFIES T14EFOLLOWING:'ICERTIFY THAT INT14EPERFORMANCEOFTHEWORKFORWHICH F- Tlil6 R Hi(B8UE0,1 SHALL NO ROY ANY PERSO SUCH A MAtNER AB TD BECOME BUBJECTTO WOIKMIW'B COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR FLA CERT B THE FO E%FY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I BNALL EMPLOY PERSONS SUBJECT TO RK M e T LAWS 0 ALIA. ANT MUST CALL M/buns 1N ADVANCE FOR ALL REQUIRED TIO Nit. COMflUIE DRAWING BELOW. BIO X TITLE: DATE: / PLOT KAN(DRAW TO SCALM SCALE.-to 1. NAMES OF S ADS NEAREST To OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAE SUCH AS PATIOS,DRRIEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ... .......... ............. .. ......... ...'.... ...... .-f ..-..-. -.......... .. .. ... , we tl......... ... .. F .......... .................. ...... ......... ...... ............. ...................... . ............... ...... ............. .,- ... .. s� . ... j Jl,'J0. .... .:. ...*r........ ... _.._ . f . > �.. ... ...........4F .. : .;:.... ..:.:.:.. 7 :.. .... .....: r . .: . : . P ...._x...199$ .. ... _ ...- �:._ }N . TY E . ... CNV RONMEN s .... Al ......_ . :....:.. . .........:..