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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 �'� (209)468-3420 NDN•REFUNDARLE PEIIMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Trlplicste) i� APPLICATION IS HEREBY MADE,TO THE SAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.C(HAA1PTEFI 9-111110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION, k - JOB ADDRESWOR APNY��pp / A• `= !�' ,J .'}�ry�y f�•� - CITY I-op I�- Lot /SIZ,3a,-G 4 OWNER'S NAME ! T�.fto(+- /��11� ADDRESS 4�� - CV0F� -�„�� ^l� �_._ .PHONE ��7 z IC z- OWNER'S _ � tl? P TY ADDRESS �' I� � te�oLIC/-PHONE__. SUB CONTRACTOR ADDRESS LIC# PHONE. TYPE OF SEPTIC WORK; NEIN INSTALLATION ❑ REPAIRIADDITION DESTRUCTION ❑ / IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BVILDING.1 PERC TE8TI.I) H—W MANY APPH—don# f INSTALLATION WILL SERVE: RESIDENCE El COMMERCIAL ❑ OTHER❑ NUMBER OF UVINO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEEO: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH_ SEPTIC TANKIOREASE TRAP ❑TYPVMF4 CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST; WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) _ LEACHINQ UNE ❑ NO,&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIOTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE l I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANDREGULATIONBOF7HESANJOAWINCOUNTV.NOMEOWNER4RLICENBEDAGENT'BSIONATVFiECERTIFIE9THEFOLLOWING:'ICERTIFYTNATINTHEPERFORMAHCEOFTHEWORKFORW}(ICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOW8 HIRING OR SVR-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPE7JBATT LAWS OF CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS. COMPLETE DRAWING BELOW, SIONEDA TITLE: Try ✓f'1 ...i:�'RLI"C... DATE: PLOT PLAN(DRAW TO SCALE?SCALE Ev - 1. NAMES OF STREETS OR ROADeRE TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WFT14 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 AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALICS. THE PROPERTY OR ADJOINING PROPERTY. C� i Y' _.. t. ... .. �u p . .. ... .Il. .. t ' .. :.....:.....:.... .....>. .. .... ..: . .. . .. . . . . .. ...... ; .. . .. .. 4 PVy,:IV L :. I 2 4riX003 _ . ... ..... isA �o a . cc�u i r ' :"� .... I FIS• fik Stl,4'4E E sir^f tka nlb'I 11 If FOR DEPARTMENT USE ONLY /' / APPLICATION ACCEPTED BY DATE: �� r AREA: 0 r f r( ?1 / ATE f�JNSPfCTIQN BW ! _.(.T� -..�OA7E �/��lL FINAL WSPECTtDN BY _ _ D ADDITIONAL COMMENTS: 4"j.) _ I .+ L a e--.7 ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMI ITED IIECICIIC eH RECEIVED BY DA7 OR!PFITMIT NUMBER INVOICE# 1 C� qq yy''}}o Pub.Health Serv.-Enviro.174(3196) /J��/1�—'f��,1,,Jt_ Gil"[. t� ZV si r PLATE 10