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APPLICATION FOR LIQUID WASTE PERMIT �2 r C SAN JOAQUIN COUNTY PUBLIC HEALTH St=iVICES ENVIRONMENTAL HEALTH DIVISION _ qq , q� 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (C6mpl&ta in Tripikat&I APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS A 1 MA 1 A H SAN JOAQUIN COUNTY DEVELOPMENT TITTLE.CHAPTER 8-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVI H VISION. JOB ADDRESSIOR APNI 3 S 16' olk� CTT`/ f�e ?{c^ LOT E y6G - �1�31 OWNER'S NAME "J O b�� c � ADDRESS PHONE CONTRACTOR I1r^ 11--// ADDRESS M 1 c LICI PHONE SUBCONTRACTOR KIP \'a IQe•� ADDRESS 2 �•�- S J ��/ 1e "f-• UCF PHONE 4k ss- 13y S' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ ^ ING SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)1 1 HOW MANY L �" Appff—tlo I 4� Ifs INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL OTHER ❑ NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ✓I �I(JC� CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/0/1EASE TMP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING UNE ❑ NO.d LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE 1I76 ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL POND& ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18188VED,1 SHALL EMPLOY ANY PERSON IN 8UCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'B COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CON4 HACTING SIONATU E INES THE FOLLO NG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I ALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION OF CAUFO IA THE APPLICANT ANT MUST CALL 24 HOUR&IN ADVANCE FOR ALL REOURED INSPECTIONS. COM DRAWING BELOW. �'� C C - DATE: /V J SIGNED X TITLE PLOT PLAN(DRAW TO SCALE)SCALE_ *tp 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, 6. 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. dry /✓.. ... ... .... .. ........... .............W -1.1--l-I.. __.. ........ ............ . ...... ............... .... .. ....... .. .... .... ... ......... ..: .... .. .... .. A _.. .. . .. .. ..... ....... .. .. .. �,� A ;. ..... .:..... 3... .. .. . . .... . . .... .. s _. a 'Al 11lIGl�ll L....:.. ........ ... .:_ _.: .... ..: ... .. ... _ :: rr f t•r4.«.f�: coo 1 1� .. .. .. - H Y AL IJEALTH OON SI N 11.`UAC] 'pUBLIG HEA ................ ....... ENVIRONMENTAL, _ ... FOR DEPAPTMENT USE ONLY APPLICATION ACCEPTED BY DATE: AREA:/ TANK,PTT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE / ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID+r FAG► PE CODE FEE INFO AMOUNT REM ITED 1 /CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE I q ID 6 21