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q k"'"_ 'Af LICATION FOR LIQUID WASTE PERMIT b.KN.,IQAQUIN COUNTY?,VBLIC HEALTH scRVICES ��.+ENVIRONMENTAL HEALTH DIVISION � �'` 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 (c(opy NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) 1,,:;.-APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT /TITLE"CHAPTER 9-1 1 10,3/AMNIO THE 8 ANDARDB/OFF SAN JOAQUIN iCOUNTYY PU,/BLLIC HEALTH (�SERVICES.ENVIRON ElNTTAL HEALTH DIVISION. ,? `/-T( `(J�` 7 (/ / v 102A 1 lam' V c'�� CITY f `C� 0/` LOT SIZE / .4 c-w— JOB ADDRESWORR A{)PN# OWNER'S NAME C- PHONE OR 'kt /7TC,� " f Ch � S kLIC(zI27SPHONE CONTRACTl 3 SUBCONTRACTOR ADDRESS UCO 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 TESTW I I HOW MANY AppHwtlon INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER 11 NUMBER OF LIVING UMTS:_ NUMBER OF BEDROOMS: L NUMBER OF EMPLOYEES: CH CTER OF SOIL TO A DEPTH OF 3 FEET ' L PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH I� TIES-1;1 TIC T K/GREASE TRAP ❑TYPE/MFG ;-11.L�'C-1 ��' CAPACITY G'� �• NO.COMPARTMENTS =� PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL p�� FOUNDATION PROPERTY UNE 7 S LIFT STATION❑ SIZE TYPE OF PUMP SAND,401L SEPARATOR(ENCLOSED SYSTEM) _ t LEACHING UNE NO.S,LENGTH OF UNE -Ie) DISTANCE TO NEARS BT:WELL � FOUNDATION PROPERTY UNE r� FILTER SED ❑WIDTH LENGTH 16&Tt4 DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE MTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 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 AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LI NSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18188UED,1 S NOT EMPLO PERSON IN SUCH M NNER AS TO BECOME SUBJECT TO WOR.KMAN'S COMPENSATION(AWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRA SIGN URE CSERTIFI HE FO OWING: -1 CE FY T AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'�COM N8 ION LA1�J8 AUFO RNI 4 HOURS IN ADVANCE FOR All REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: `� DATE: PLOT PLAN(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 AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ...;..... ........ ._ .._ .. ..... .... i ..:......: ...,.. ...... '..i.... ............:............: . .. .. .. .. ...... ..... ........:... ..:.. ..: . ..... ..: ... i.. .:.. .. .. (00 .... ..... .. Z� �, 2c- ................. . ... .....`.. .. . . ��.:�. .... . .. _ _ ... .. PAYME ... .. -C E _ . ... ... ... ... ... .... ..... :.. AY.. 21998 cc uvvrY PU9LIC FOR DEPAPTMENT USE ONLY VIRONNI'EN-AL HEALTH DIVISION ��+�• �- AREA: APPLICATION ACCEPTED BY \ l\o \�(7�.- -�----- DATE: TANK,PIT OR SUMP INSPECTION BY DATE��FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: � `A )` c ��r h.o I.(- S -Q-✓Ll ACCOUNTING ONLY: AID# FACS PE CODE FEE INFO AMOUNT REM(ITED CHECK ASH RECEIVED BY DATE SA/PERMIT NUMBER INVOICE O j 44 Pub.Health Serv.-Enviro.174(3/96)