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`- APPLICATIONFOR L1QUIO WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 FAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 400 REFUFIDABLE PERIVIII EXPIRES I YEAR FROM DATE ISSUED 05� (Complete In Triplicate? APPLICATION 1$HEREBY MADE.:r0 THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. TMS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TrTLE,CHAPTER 9-1114.3 A, °THE STANDARD@ OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, It /y JOB AUQRESOMFI APNI CITY C% r LOT SIZE. L ` 1 C OWNER'S NAME R r ! ADDRESS 4(5 �J 0 , dp�T PHONE 6 / `/�l/ 1? CONTRACTOR OZ ADDRESS � r UCI 'T' l PHONE -! wr SUB CONTRACTOR ADDRESS UCI Ffl/F TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION ❑ 511777,17 INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.I PERC TESfW 1 1 NOW MANY APd1onllon I i F INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALS OTHER ❑ NUMBER OF LIVING UNIT$., NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES! r.y/��J{)pt_A)II`J CHARACTER OF BOIL TO A DEPTH OF]FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH PUBLIG I,}_i',};f 11 Sl�,fi111f�i:�.: s1FPTTc TANIVOItIJIBE TRAP .- A i:IJV1?;pMI:Mti�li Iil.i ITkI 1)PJI11114 ❑TYPE/MFG �-C CAPACITY 2 Q NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION© SIZE TYPE OF PUMP SAND OIL SEPARATOR)ENCLOSED SYSTEM) r, LEACHING LINE ❑ NO.a LENGTH OF LINES. �^J � - - ._DISTANCE TO NEAREST:WELL 1;'�b �F TOUNDATION PROPERTY LINE FILTER BED ❑MOT" LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑VNDTH LENGTH PUT" DISTANCE TO NEAREST:WELT FOUNDATION PROPERTY UNE SEEPAGE PITS 11DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION /rte PROPERTY UNE SUMPS ❑WIDTH / LENGTH 1.Sr� DEPTH S _DISTANCE TONEAREST:WELL�r�0__ F6>0 tFOUNDATION , PROPERTY LINE / J DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED T1418 APPUCAT40N AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSIED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING!'I CERTIFYTHAT INT"E PERFORMANCE OF THE WORKFOFW"fCH THIS PEFtmrr 18 IB8UED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOVKMAN'B COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'$HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNI THE APPLICANT MUST CALL 24 HOUR$IN ADVANCE FOR ALL REQUI"ED INSPEC GNB. COMPLETE DRAWING BELOW. SIGNED X TITLE: Y U DATE: -PLOT FLAN tDRAW TO SCALE?SCALE 'to T. 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, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. - THE PROPERTY OR ADJOINING PFIOPERTY. ..- . ......, .. .. .... .. .... ... _ p r ' .... ....... . . ....,... r'u L, 4 S.... .. .. - ... .:... . . ..... . r�S ...... - rim ----s. .. c v ... . . . +tifU. C{R .c�ev t "'b }D PIP st`��Pr.Earl !�-�....:. .8 �.. . �.. �r .Z .. ..... 57 .... .......... ...... .......... .... ....... ... .....i ... ..... 3 FOR REPARTMENT USE ONLY .yam r APPLILATION ACCEPTED BY 6� DATE: AREA: �. 4 � ••,-- TANK,PTT OR BUMP INSPECTTIION BY /• p PATE ! ! FINAL INSPECTION BY - DATE ( ADDITIONAL COMMENTS: J'�-T 1 ACCOUNTING ONLY: AID) FACT PE CODE FEE INFO AMOUNT"EMI ITER CHECKI/CA H RECEIVED,RY DATE OR I PTAMIT NUMBER INVOICE I Pub.Health Serv.-Enviro.174(3/96) PLATE 12 Iv, -