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\ �v APPLICATION FOR LIQUID WASTE PERMIT 11 ,,i1 JOAQUIN COUNTY PUBLIC HEALTH --RVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 46&3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complot• In Tripikstll APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION I8 MADE IN COMPLIANCE WITH SAN D/ JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111,0 'AND THE STANDARDS OF BAN JOAOVIN COUNTV PUBLIC HEALTH RVICES.ENVIRONMENTAL H ALTH DIVISION. JOB ADDRESS/OR A -7 /- I�OT 911E /3n��?�✓ �,�C�y ADDRESS PHONE OWNER'S NAME /� r CONTRACTOR SL�'/ ADDRESS 5Lc? � .ST UCP PHONE {�^ SUBCONTRACTOR e_ -A7 l,r� _ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIO I 1 HOW MANY Aplog—don.1/ INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LANG UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.t LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH 911E NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHAM EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS. COMPLETE DRAWING BELOW. . BIOMED X TITLE: 0 l DATE: :1Q> - �_ {n+� PLOT PLAN(DRAW TO SCALE)SCALE_ 'to \1 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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAB SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. Q . .. i.... ..... .. .. _.:.... .. .... ......._ .. ..... .... .......... r . .. . .... ... [.� .. .. _ ... ....... ........_....... Shy PAYMENT ...... _J q� 22 100 .... . . N G NTY l (X� �' Y Q... pfJBIIC f+FhtFH FPVIGES l....ET1V AN 30ApUl FOR OEPAPTMENT USE ONLY L: APPLICATION ACCEPTED BY -1 DATE: / v—=n AREA: TANK,PIT OR SUMP INSPECTION BY DATE V. / � FINAL INSPECTION B a l I D11TE ADDITIONAL COMMENTS: 0 ♦ ` 4 ACCOUNTING ONLY: MOI FACT PE CODE FEE INFO AMOUNT RENIIITED ITEC ASH RECEIVED BY DATA SR/PERMIT NUMBER INVOICE J � > � a Pub.Health Serv.-Enviro. 174(3/96)