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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTti-SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 SEP NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplie&t&) APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE68MR APN/ 1 Xy ,fo zIT�I,-/` CITY /�/fJ��J/-�'/! LOT SIZE OWNER'S NAME li/L/i11 ,1�///�/Jy � ADDRESS jQ 4F pel; �yJ j//fir /1��1 2� �y�, PHONE CONTRACTOR / i �// 7[� ADDRESS LIc� PHONE J6?,r 5�"Z;z`n, SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AUDITION DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) P6RC TESTI.)I I HOW MANY 0 AppNo.tlen INSTALLATION WILL SERVE: RESIDENCE ElCOMMERCIAL 11OTHER 11 .2 pe-t Sid• NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOM&: L~ NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKUGREASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS LIgtr v l PKO TREATMENT PLANT 11 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE `()�K� f 1 iv LIFT STATION❑ SIZE TYPE OF PUMP // SAND OIL SEPARATOR IENCLOSED SYSTEM) Tr— TLEACHING UNE 0 NO.i LENGTH OF LINES �7- 7(� F T DISTANCE TO NEAREST:WELL/��L7r�FOUNDATION ��F PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ®WIDTH LENGTH• ) / DEPTH��/ DISTANCE TO NEAREST:WELL//"4! 'f T FOUNDATION ~r PROPERTY LINE 4::5 �- DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 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 OWNER OR UCENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 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 SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'1 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 CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TRCE— y�, DATE: PLOT PIAN)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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY.. oci _I L. .... ... ...... 2 ..... ..:.. . _.. . _ :. A _ IPA y8 - _- ... FEB --..... `_ :o.d.. 61999.1 3 lSA7l JU :t(jll�41 t113�t:, PU�ZiC 1-j F7H SEcFtVICEb ... ..� ENV180NMF. L t1�AkTH Dt/ISIUw FOR D AR ENT USE ONLY �n l APPLICATION ACCEPTED BY� t %`�/\`II�7 DATE: AREA: r� TANK,PIT OR SUMP INSPECTION BV / DATE / / FINAL INSPECTION BY DATE 3 / C ADDITIONAL COMMENTS: -/ 4/��. /u U 11 ` S f RO� T` IV 3,2�4 CZ P,c ACCO UNRNG ONLY: AID# FAC.► PE CODE FEE INFO AMOUNT REMII TED CHECK/ ASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE 0 Pub.Health Serv.-Enviro.174(3/96)