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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comptsto in TTipiicste) APPLICATION 19 HEREBY MADE TO THE RAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED, TI118 APPLICATION IR MADE IN COMMJANCE WITH RAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. IZEJOLOT SIZE,.- JOB B ADDRESe/On APNf >� lL✓ r;7 I r L/! PHONE OWNER'S NAME � ✓V.�•�! ADDRESS Yi . UCf %5 L/L /S PHONE � ADDRESS `l/S CONTRACTOR UCf PHONE ADDRESS SUB CONTRACTOR FF�� TYPE OF SEPTIC WORK: NEW IN87 ALLATION ❑ REPAIR/ADDITION W DESTRUCTION ❑ PFRC TERIbI 1 I HOW MANY IND SEPI IC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING-1 Appg—d—f INSTALLATION WILL SERVE: RESIDENCE to COMMERCIAL ❑ OTHFn ❑ NUMBER OF AMNO UNITS: i OF BEDROOMS:� B _ NUM91 OF EMPLOYEES: _ NUMBER WATER TABLE DEPTH CHARACTER OF SOIL TO A DEPTH OF 3 FEET! 'M..t.` ! +s- PITISUMP SOIL CHARACTER: -411 NO.DEPTH coMTMEN78 ❑TYPE/MFG CAPACITY SEPTIC TANKUOREASE TRAP PROPERTY UNE PPLO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION — 0 STATION❑ SIZE TYPE OF PL1MP SAND OIL SEPARATOR IENCL06FD SYSTEM) PROPERTY UNE LI ❑ NO.•LENGTH OF LINES) !//� ✓T' �1 DISTANCE TO NEAREST:WELL / 11.) FOUNDATION - . LEACHING UNE FOUNDATION PROPERTY UNE Ll WID1H LENGTH DEPTH DISTANCE TO NEAREST:WELL LILT ER SED FOUNDATION PROPERTY UNE DEPTH DISTA ❑ LENGTH NCE TO NEAREST:WELL _ MOUNDED WiDTH S 1 FOUNDATION -O`? PROPERTY ?c, SIZE %, NUMSER�_DISTANCE TO NEAREST:WELL _ SEEPAGE PITS l.f DEPTH PROPERTY UNE •� DEpTII DISTANCE TO NEAREST:WELL FOUNDATION SUMPS ❑WIDTH LENGTH FOUNDATION PROPERTY LINE _ DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL 1 HEREBY CERTIFY THAT 1{RAVE L'REPAREU THIS APPLICATION ANb THAT THE Wow WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ✓j FOLLOWING!'I CERTIFY THAT IN THE S THE 711 8 PERMS IR ISSUED,1 SHALL"Or COU TY.HOME OWNER OnLICENOED M SUCH LI MANNER AS TORBECOAT RE CERTITIE WORKMAN'S CCOMPENRAT ON LAWS OF CAUFFORNIAAV''C CONTRACTOR'S INNO ORANY �/ lie CH WORKMAN A C MPENSSIGNATURE CERTIFIES OF CALIFORNIA.'FOLLOWING: 'I CERTIFY E HINT MUST CALL 24 g11R6 IN ADVANCE FOR AT IN THE PERFORMANCE OF THE WonK LL REOUIInEOTINSPEC�ONS.IT 19 ICOMPLETEE DRAWING BELOW.SSUED,I SHALL EMPLOY PERSONS SUBJECT TO - ./�� •! TITLE: ' 1 / DATE: /i'1� r SIGNED X PLOT PLAN IORAW TO SCALE)SCALE_ 1n r' 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED / 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDINO THE PROPERTY. EXPANSION OF SEWAGE DIRPORAL SYSTEMS. 2. OUTLINE OF THE WTOPERTY,WLTH DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON 3. DIMENSIONED OUTLINES AND LOCATION OF All EXISTINO AND PROPOSED STRUCTURES, THE PROPERTY OR ADJOINING PROPERTY. —_ INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. f• 9 \� rL _ .. 7 I 11998 ,_ - _ �►AY 1 w it i c;GUNl _... ! . ..... .... ... r i ; FOR DEPARTMENT USE ONLY �NVIRONNiENI AtHF_ H pIVISIU DATE: APPLICATION ACCEPTED BY / f DATE ! ! FINAL INSPECTION BY - DATE ✓ U�J l Ua TANK,PIT OR SUMP INSPECTION BV ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FACE — SR U PERMIT NUMBER INVOICE f PE CODE FEE INTO AMOUNT REI TED CHECKfI ASAI RECEIVED SY DATE / Pub.Health Serv.-Enviro. 174(3/96)