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APPLICATION FOR LIOUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION C (a py 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplato in Triplieabl APNICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY Mg A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORE DESCRIBED. TIII8 APRICATION IS MADE IN COMPLIANCE WITH BAN "AMIN COUNTY DEVELOPMENT TITLE,CHAPTER /9.11100.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISQN. JOB ADDRESSOR/AAM0 1'/✓rJ ✓ {`A I{��/E•� _//�/'/�/ -/-/ ✓,��1 CITV/ LOT SIZE _ OWNER'S NAME `-��`LVAR�`'4l I�JVWL IiI��E/�«l ADORESR oI? ai ox X14; r}LO Dl L�5 Z v PHONE /f Q- 9iyio CONinACTOn VA LI-��f�l /\�/EARL(( ADDRESS r -49, Ro/K S 7�� /u��rK LACI PHONE (/SSV SUB CONTRACTOR ADDRESS llC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPNR/ADIXT10N ❑ DESTRUCTION ❑ ,NO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER 18 AVAILABLE MTHIN 200 FEET OF BUILDINO.I PFAC TUTHI 1 1 NOW MANY AppMcatlen I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UMTS:_ NUMBER OF BEDROOMS: NUMBER OF EMROYEES: CHARACTER OF SOIL TO A DEPTH OF J FEET: PT/SUMP SOIL CHARACTER: WATER TABU DEPTH SEPTIC TANKATRFASE(AAP ❑TYPEMFD CAPACT' NO.COMPARTMENTS PKU TREATMENT RANT❑ DISTANCE TO NEAIIEST: WELL FOUNDATION PROPERTY UNF ENT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.B LENGTH OF LINER DISTANCE TO NEAREST:WELL FOUNDATION A PSRTY LINE FILTER BED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE ATS ❑DEPTH S1ZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LLNOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATON PROPERTY LINE I HERESY CERTIFY THAT I HAVE PREPARED THIS APAICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUINCOUNTY.HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIEB THE FOLLOMNO:•1 CEMIFYTHAT IN THE PEIPOR NIANCE OF THE WDA(FOR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUWECTTO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB CONMACTINO SIGNATURE CERTIFIES E FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMB ION LAW�re [A.' PLCANT MUST CALL 2A HOURS IN ADVANCE FOR ALLREQUIRED INSPECTIONS. COMRETEDRAWINGBELOW. SIGNED% ' TNLE: (2 Al GATE' llh////YYY\ ROT N DRAW TO SCALE(SCALE_, � 'to TS v 1. NAMES OF STREEOR ROADS NEAREST TO OR ROUNDI THE PROPERTY. /v/e SCAR-'CA. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOBEO 2. OUTLINE OF THE PROPERTY.WTTH DIMENSIONS AND NORTH DIRECTION. EXPAN8IDN OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADNB OF ONE HUNDRED FIFTY R.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS, THE PWPEITTY OR ADJOINING PROPERTY. -0 01-,7N Ntia� DEC 1 1998 SAN JOA0U1N COUKTi 1I11,^, �u,I 1 PUBLIC HEALTH SEFNICES I- ^ -,(��pjNAl.�,t7W !7(/US 1V� NVIRONMENTAL HEALTH DIVISI wat mogi- r�N ZIVEFfz DEPARTMENT USE ONLY Z 1 vl AREA' C APPLICATION ACCEPTED BY /' /�S� 1 DATE: ` e// RAIN., AT OR BUMP INSPECTION BY DATE I / FINAL INSPECTION BY 4 ✓ DATE / ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID/ FAC/ PE CODE FEE INFO AMOUNITIMIITED CHECK/ ASH RECOVED BY .ATE SR/pOWST HUMBER INVOICE♦ 2 Pub.Health Sen.-Enviro. 174(3/96)