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PPLICATION FOR LIQUID WASTE PERMIT SAn'JOAQ COUNTY PUBLIC HEALTH SERVICES Capy ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. q JOB ADDRESSKOR APN# a S K CITY, /T Y"1L � LOT SIZE l'I,KRLI OWNER'SNAME ( L,7AR%f'- ADDRESS e��✓•� � �15y` �C� _PHONE CONTRACTOR (03L._ -� !J! :1Q– __ ADDRESS �`�-� S -Y•'4L� v\\ra LIC# 3CJI�1-DlI PHONE 3 " SUB CONTRACTOR —T ADDRESS UCR PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIAODITION Uk DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.( PEAC TESTIal 1 1 HOW MANY Application # INSTALLATION WILL SERVE: RESIDENCE El COMMERCIAL❑ OTHER ❑ NUMBER OF LIVING UNITS:( NUMBER OF BEDROOMS: S NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: Cl f}R PT/SUMP SOIL CHARACTER: 'Tn d WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP ❑TYPEIMFO CAPACITY NO.COMPARTMENTS N PKG TREATMENT PANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE p LIFT STATION❑ SIZE TYPE OF PUMP U SAND OIL SEPARATOR(ENCLOSED SYSTEM) r O LEACHING LINE &NO.S LENGTH OF LINES / 7C. /a r DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE /T� FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE V' SEEPAGE PTBDEPTHS- SIZE iib« NUMBER DISTANCETONEAREST:WELL S�FOUNDATION10 PROPERTY LINE //10' C SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN 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 THEWORK FORWHICH /v THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR A SUB-CONTRACTING SIGNATURE CEFffIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LA OF CALM IA.' THE APPLICANT MUST CALL 34 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPETE DRAWING BELOW. I SIGNED (.� X��,=C///ry/ TITLE: lnf.O✓RLT�- DATE: 4-`1>61 %I PLOT RAN(DRAW TO SCALE)SCALE 'to 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 MEAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. Y�1.0 01 T ti T PAYAME F _ A;P R 2 5 1996 g !...... PU13LIPHfiALTHSLAVIC, t YIRQNMENT.ALktEALT}+Dsv :., II