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1 APPLICATION FOR LIQUID WASTE PERMIT f' SAI%--JAOUIN COUNTY PUBLIC HEALTH SE', ✓CE5 ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)46843420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Complota In Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JDAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1110.3 AND THE STMOARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OIVISION. JOB AODRESSIOR APNI F Cf;Y LOT SIZE OWNER'S NAME -� l ADDRESS PHONE CONTRACTOR �� L•�" ,ADORES6. � #. PHONE P LICA' RIONE SUB CONTRACTOR ADORES' TYPE OF SEPTIC WORK: NEW D1TIO INSTALLATION ❑ REPAIRlAON' DESTRUCTION ❑ ENO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET Of BUILDIHG.I PERC TE$Thl 1 1 HOW MANY ApPH°atlon# INSTALLATION WILL SEINE: 1RESIDENCE 14 COMMERCIAL ❑ OTHER 13MW NUMBER OF LIVING UNITS, Na r NUMBER OF BEDROOMS: NUMBERS OF EMPLOYEES: �I CHARACTER OF SOIL TO A DEPTH OF 9 FEET: PITBUMP SOIL CHARACTER: r WATER TABLE DEPTH n I SEPTIC TANKRRFASE TRAP ❑TYPE?MFO CAPACITY NO.COMPARTMENTS XI �} PKO TREATMENT ANT 0 DISTANCE TO NEAREST: WELL A7_w,7—_w,7— FOUNDATfON� PROPERTY LINE �Q RFT! UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR{ENCLOSED SYSTEM; I FOUNDATION PROPERTY LINE LEACHINGLEACHINGUNE ,IL�Sy,,�, NO.d LENGTH OF LINES� , T DISTANCE TO NEAREST:WE 5 ALTER BED LJ WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL 1-0UHQATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH 82E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FOUNDATION - F PROPERTY LINE SUMPS ja WIDTH LENGTH Zd l OEPTHl�DISTANCE TO NF.ARIE WELL . DISPOSAL PONDS 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE - DISPOSAL HERESY CERTIFY THAT I RAVE PREPARED THIS APPLICATION AND THAT THE WOW WEU,BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONBOFTHE SAM JOAQUIN COUNTY-HOMEOWNERORUCENSEDAGENT'SBIOHATURECERTiFIEBTMEFOLLOWING:'ICEIRTIFYTHATIrNTHEPERFORMANCE OFTHEWNORKFORWHICH _ THIS PERMIT 18188UE0.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME BU&MCT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' COMFLACTOR'S HIS ING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS 188UEQ.1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTION$. COMPLETE DRAWING BELOW. /✓/` �.[i TITLE:: DATE: SIGNED X�ep- _♦ PLOT PLAN IDRAW TO SCALE)SCALE_ 1a 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED S. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY- EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, THE PROPERTY OR ADJOINING 1'ROF'ERTY, i INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. 7 i .......... .. ; :. .. 73� . .. k :: ......: iia r ' .. : .. .. - ... AY .1. 1998 r r G ' SAN BtJOAQUIN Gu Uhrt -tCfAj$&TH SERV[Cjw S _—� - FOR DEPARTMENT USE ONLY -- DATE: AREA: APPLICATION ACCEPTED BY t^ c c. p TE J TANK,PIT OR SUMP INSPECTION BY �c "$ DATE ' ! FI AL INSPECT N Y ADDITIONAL COMMENTS:` . i ACCOVNTTNG ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REM117ED }PLIC /CASH RECEIVED BY DATE aR!PE3LMIT N INVOICE# Pub.Health Seiv.-EnvirO.174(3/96)