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i 0'- DD APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SrAVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 W' [Py NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplieste) APPLICATION IB HEREBY MADE TO THE SAN 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 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE88/OR APN/ �4na^-o�Dnn��-,�//�yO^ �S/lo /I��W7M 4b. CrrY .AST/D'�C�TO� ��_/LOT SIZESAC AC, �448j2d r OE reAL ADDRESS /1/.� SAHAl,+1 /eA, S72e-k-MN PHONE 'f�o(o-/rO�/ OWNER'S NAME T� 1E � �-�PHONE CONTRALTOADDRESS L � f„ LkJLic,71II= �_ U�Q7 J SUB CONTRACTOR ADDRESS uC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ IMO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) pE{C TESTI.)I I HOW MANY APP11-ti-Ir- INSTALLATION WILL SKIVE: RESIDENCE❑ COMMERCIAL I/ OTHER ❑ 1 NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: { NUMBER OF EMPLOYEES: WATER TABLE DEPTH T I CHARACTER OF SOIL TO A DEPTH OF J FEET: �SI/l PIT/SUMP SOIL CHARACTER: rnJj SEPTIC TANKMRE"F TRAP ❑ TYPE/MFG Eur I&^j CAPACITY t JT/✓ NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEMEST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) ^ / LEACHING UNE ❑ NO.B LENGTH OF LINES ///yyy_K DISTANCE TO NEAREST:WELL FOUNDATION D� PROPERTY UNE 0(O FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE ATS DEPTH��SIZEi _NUMBEhI / DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES TV AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH \\l THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION& COMPLETE DRAWING BELOW. TRLE: DATE: SIGNED X -� PLOT PLAN(DRAW TO SCALE)SCALE_ -10 Q V`^� ^ �08ED/ I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 1. LOCATION OF HOUSE SERA E d 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL By S. 8. LOCATION OF WELLS WITHIN RADIUS D FIFTY FT.ON 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, THE PROPERTY OR ADJOINING I t \ INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS. (-v` }f 5 l�ER pG¢l�lS t SPECS, �iE'o�.. St�6f'A�ei� E�li��s/��°i y' ,0 0 ... _ z .. ` p n o _.... . ............. ..............{...............;... .......... .. .. ..4. .................................. .. ..: ........:............ . ....................... .. .. .........:.... .. .. ......... ..,... .. .. .. . .., ,....:..... . :. ..: ........ \ .... ...- . ... . . ................... .:. _. .. ..... .......;.....�....... .. t �.. �aAM JJAUIJIN G.JuNII'.: rUBLlC HEALTH SERVICE =!VVIR ONCE hETAt 111wrt1 TH,f)V FOR DEPARTMENT USE ONLY 7 -�v � APPLICATION ACCEPTED BY DATE: ... AREA: TANK,PIT OR SUMP INSPECTION BY / DATE FINAL / // FIIN'AL INSPECTION BY �+�� /DATE I T / / ADDITIONAL COMMENTS: �'��4l.� /�S lY7�An" �(� �/Y5 L//�d 1. /Y�� SL'!i Cilll'1�L�G 71�'X fes/' 'PA'x 'AJ 2 i. G1 3 4`7 /1/1-,�'? I ACCOUNTING ONLY: AID( FACS PE CODE FEE INFO AMOUNT REMIITED CHEC ASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE L. Pub.Health Serv.-Enviro.174(3/96)