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APPLICATION FOR LIDUID WASTE PERMIT SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,446 N.SAN JOADUIN ST.,STOCKTON,CA 95201 0388 (209)468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (C—pl.0 i.TTipli..n) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND10R INSTALL THE WOW DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111100.-3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH ERI—,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN, 9no '`� /fI/// /L-® ! �r•,�1 CITY V I%/�J7 LOT SIZE a OWNER'S NAME P .P✓ ADDRESS 940 >K/rn,•+� `/ PHONE CONTRACTOR ) 1u AOORESS�/-:?-5 L -��7 aZ LICE 72499,1 PHONE Y4�3�79J SUB CONTRACTOR ADDRESS UC, PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDIT...Ur DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PFRC TESTI.1 I I MOW MANY Aodm..oR. INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL- OTHER 11 ,A I NUMBER OF UVINO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEEf: 111J r41Y.v ) CHARACTER OF SOIL TO A DEPTH OF 3 FEET:MTISUMP SOIL CHARACTER: Zf' 4L' WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP [I TYPE/MFG CAPACITY I NO,COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATIONERTY_ PROPLINE - UFT STATION❑ 51 TYPE OF PUMP SAND OIL SEPARATOR,ENCLOSED SYSTEM, �T LEACMINQ UNE NO.L LENGTH OF LINES �O/J DISTANCE TO NEAREST WELL .�F>� FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ,❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL ' FOUNDATION PROPERTY UNE_ SF�P...AT. IL�f DEPTH SIZE_NUMBER I- DISTANCE TO NEAREST:WELL [t), FOUNDATION PROPERTY UNE d SUMP. ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DIAL POND. ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOE.(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PEPFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWMAN'S COMPENSATION LAWS OF CALIFORNIA."CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TH FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP�II TI N LAWS OF FOR IIA.'THE APPLICANT MUST CALL 24 HOUR.IN ADVANCE FOR ALL REQUIRED INSPECTIONS.'COMPLETE DRAWING BELGW. 'y SIGNED VZ i� TITLE: bE" ."` >s.� DATE: ROT RAN,DRAW TO SCALE)SCALE 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.DIMEN610NED OUTUNES AND LOCATION OF ALL EXISTING AND PHOPOSED STRUCTURES, ..LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WAIXS. THE PROPERTY OR ADJOINING PROPERTY. �T DN AUG 10 1995 SAN JGAQIJII .,L—I, PUBLIC HEALTH SERVICE: ENVIRONMENTAL HEALTH p Vl-i t � V - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -_� DATE: S AREA: E-^ TANK,PIT ON SUMP INSPECTION BY DATE i FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: O �+• •_ ,� s .��, . ACCOUNTING ONLY. AID, FAC♦ L•LJ lY- CItL.:e��.P•vT"`^T� / PE CODE FEE INFO AMOUNT REMITTED CNECKI A6H RE.DV FD BY DATE 6R/P-IT NUM66t VOICE l Z (o!1/ /0 ' o44,Q FAY CF