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LIQUID PERMIT ,V APPLICATION RWASTE bAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, 9A l 9_52(U T� (209) 468-3420 D NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TTiplksts) APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN �JJpJAOUIN OU/j{)TY PUBLIC HEALTH SERVIC/E�SS,ENVIRO.WE[NT EALTH DIVISION. l'� I �` Vj i 1�"' Gl �\ 'V v/V V LO SIZE / t� JOB ADDRESS/OR APN# V 7 , OWNER'S NAME r� 1.. ✓✓// ADDRESS /y�� - L - rPHONE CONTRACTOR ✓ r �"�I I �tDRES6C��--"� L1CI Of �1•u �� SUBCONTRACTOR 1/JI� ( / ADDRESS /�J '\ "C.�� •VPHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPMR/ADDITION DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW I 1 HOW MANY ��yy Applimdon INSTALLATION WILL SERVE: RESIDENCE M COMMERCIAL ❑ rr/� OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES:- N\/V CHARACTER OF SOIL TO A DEPTH OF J FEET: Pjj18UMP SOIL CHARACTER: ATER TAB SEPTIC TANK/GREASE TRAP 0 TYPE/MFG 1 �{- /\/\ e•L'l�� I�-CAPACITY b NO.COMPARTMENTS r}-� Q PKO TREATMENT/'LINT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE (,,T 1 • UFT STATION 4,ySIyn TYPE OF. UMP_SAND�OIIL SEPARATOR(ENCLOSED SYSTEM) -1 LEACISNO UNE L!]"f10.A LENGTH OF ONES I..�F'�--(-1 STANCE TO NEAREST:WELLJI' J t IOUNDATION it �- PROPERTY UNE /� 1 FILTER SED //(❑WIDTH LENGTH DEPTH / 61STANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION 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 WOW WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE8 AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT 18 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 SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THEZAPPUC� MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INBPECT10N8. COMF'IETE DRAWING BELOW. i l 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, 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 PROPERTY. _ .. ------ ... .. .. . . og° . . . . . .... . . .. ... . .. . ...... . ........... � . . >�.. Z _ 1 ............... SOV . ��,�11 ........ t1' JHOUIN Ijvry Lem'" :: ( IV\�iRO WEN l�E,1� RViCES _. . r;IIC' . .. rVISION L /VtS.WeC✓ Cwt w4 Ate• FOR DEPAPTMENT USE ONLY APPLICATION ACCEPTED �/i � GATE: I/ '/ ��r// AREA: c, TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY KJ.k�t� DATE ADDITIONAL COMMENTS: 0a /f ACCOUNTING ONLY: AID# FAC# PE CODE FEE INTO AMOUNT RE"LIEP HE I{pR/CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE# Pub.Health Serv.•Enviro. 174(3/96)