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APPLICATION FOR LIQUID WASTE PERMIT <br /> b'AN'JOAQUIN COUNTY PUBLIC HEALTH SERVICE, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.0388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,,C/H"AAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Q�y <br /> JOB ADDRESS/OR APN# �� �5!11,/ C _ �+I ��� l / Ca /-� ��/7 CITY �� aft) �_C_� LOT SIZE�D—I I l-1 <br /> OWNER'S NAME e� 1� _ ADDRESS C +nn�-:(U 1 /V�L� (� J PHONE / �- <br /> CONTRACTOR ` ADDRESS yd. 01 LIC# 2- PHONE�`n� 8Cj6_ <br /> SUB CONTRACTOR ADDRESS LIC# PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION ❑ DESTRUCTION ❑ <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC-SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIS)I I HOW MANY <br /> ,1 APWioatlon Jr <br /> INSTALLATION WILL SERVE: RESIDENCE 7""� COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: Cl PIT/ UMP SOIL CHARACTER. C1. C WATER TABLE DEPTH Is <br /> SEPTIC TANK/GREASE TRAP TYPE/MFG ' �' CAPACITY NO.COMPARTMENTS <br /> PKC TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> LIFT STATION❑ SIZE TYPE OF P SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING LINE NO.&LENGTH OF LINES X "�1JJ D" DISTANCE TO NEAREST:WELL 15o FOUNDATION� PROPERTY LINE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION_PROPERTY LINE <br /> SEEPAGE PITS DEPTH _SIZE .��6 NUMBE DISTANCE TO NEAREST:WELL FOUNDATION r_r PROPERTY LINE <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE fin.. <br /> o ' <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FORWHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO t-\ <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. �J <br /> SIGNED X / 0- �, TITLE (-)�.­xlt-Q, _ 6 C_ DATE: <br /> PLOT PLAN(DRAW TO SCALE)SCALE "to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PfiO POSED STRUCTURES, ��j 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. V THE PROPERTY OR ADJOINING PROPERTY. <br /> ....... ... .. '... . .. .... ........`. .. .. hC .. .. .. . .. <br /> _... ;. .... . ....:. .. _. . .. .. . . <br /> ................ ...... ................. .. ............. ... .. .............................. .- ... <br /> .. .: .. .. ..; .. .. <br /> ....... .. .. .. 1.- <br /> .' '.. ..... ..... ..,. 1 ... <br /> Q A <br /> _. ... _ .... ..... .... \ <br /> '... .... . <br /> _ __ <br /> QL <br /> y <br /> ....... .... .... .. _ . <br /> ... i fl <br /> ......: ...,. .�Y....__ . <br /> .. .. .. ....... .... .. . _ _ .................. .. , .. <br /> MAY <br /> p `1995 '.. <br /> ..... ..:..... .. ...... <br /> SAN'J0 4UIN€-O.UNT.x. <br /> CEC. <br /> ....... <br /> PUBLIC HEALTH SERVI <br /> NMI;NTAI HEALTH D)VI JQN <br /> FOR DEPARTMENT USE ONLY , <br /> APPLICATION ACCEPTED BY DATE: A <br /> Al / OR SUMP INSPECTION BY DATE/ U/ FINAL INSPECTION BY ATE ! %s <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: I AID# FAC# <br /> PE CODE FEE INFO AMOUNT REMITTER, NEC /CASH RECEIVED BY DATE SR!PERMIT NUMBER INVOICE# <br /> i <br />