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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH _RVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 lJ (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complato in Triplieats) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. CITY t7 l LOT SIZE ADDRESS/OR APN/� .� �� • C•�/,r/ PHONE OWNER'S NAME r I�n.'� / } / -'/ti4 -. ADDRESS1�/.J CONTRACTOR ' �C7w-t•�'/ A1C^/i r C> �' /)XX PHONE � �" c //�S '/��A�/.�ADDRESS - SUB CONTRACTOR ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 771 ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)1 1 HOW MANY App6imdon J INSTALLATION WILL SERVE: RESIOENCE_%2r--COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UMTS:_ NUMBER OF 8E/�,RODMS: �� NUMBER OF EMPLOYEES: CHARACTER OF SOIL TOA DEPTH OF 2 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH �f—A T SEPTIC TANK/GREASE TRAP ❑TYMWFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION 1-1 SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) / LEACHING LINE 10 NO.S LENGTH OF LINES / � DISTANCE TO NEAREST:WELL j/2i� � FOUNDATION ` PROPERTY LINE V FILTER RED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE NTS ;0-DEPTH SIZE R DISTANCE TO NEAREST:WELL,X FOUNDATION �C� PROPERTY LINE % !� w �`> � SLSNPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I 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 IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENOATKON LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED)( / ]//// �� /� / TfTLE: `-�� DATE: J PLOT PLAN rDRAW TO SCALE)SCALE_ 'Ro 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. ... .............! . . . c l . .. :y, ... . .. ..... ... . . Q GAE ........ ... .. -- C .. .... _ _........ __.... . _: ... _..... _ r Q ..... ..... -. _ . .. ..... pp ...... ..... t f'U LIG Hd'-TS SL Vd, C/JViFiClf�iwE+JTA,F i#Fp F,�,>/ISy., v _ . `u G _ _ .. ..... _.. . .. .. FOR DEPAPTMENT USE ONLY IC APPLICATION ACCEPTED BY '� V�' 1 0A DATE: -3I /cl AREA: L / DATE l�y `FINAL INSPECTION BV // / DATE` I TANK, R SUMP INSPECTION BV / ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID/ FAGt PE CODE FEE INTO AMOUNT REM( TED HEC (CASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE t CKO ) Pub.Health Serv.-Enviro.174(3/96)