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APPLICATION FOR LIQUID WASTE PERM17 SAN JOAQUIN COUNTY PUBLIC HEALTf SERVICES A� ENVIRONMENTAL HEALTH DIVISION � �(/ 304 EAST WEBER AVENUE, STOCKTON, CA 95202(209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( v l v ( (Complete In Triplicate) / APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH A F` JOAQUIN COUNTY DEVELOPMENT LE,CCH/HHALA��,,PTER 9-1110.3 IAND THE STANDARDS OF SAN JOAOUIN CO NTV BUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. � (C-) JOB ADDRE68/OR APN+1 ��/v7 ,_.L/tf /�� CT-Y `--�-� LOT SIZE p�`' OWNER'S NAME 6fie �16Q` /� ADDRESS CA� PHONE C/O CONTRACTOR ADDRESS /�J/L UCR [�/ PHONE /�� J 7 U7 GUS CONTRACTOR UCI / 2� PHONE YC 7` J ( J TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIRIADDITION ❑ DESTRUCTION ❑ PERC TESTI)l 1 HOW MANY IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) / P v ^ ADPSoetlon INSTALLATION WILL SERVE: RESIDENCE[I COMMERCIAL 11OTHEFFX t LLy' NUMBER OF LIVING UNITS: NUMBER /OFgSEDROOMS: NUMBER OF EMPLOYEES: / iQFAT'.-":-'I:.TT F SOIL TO A DEPTH OF 3 FEET:Z-ea It PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH`-, �5 Q�� /Gj O O NO.COMPARTMENTSAP ❑TYPE/MFO v/`� J/'�>' CAPACFTY❑ DISTANCE TO NEAREST: WELL FOUNDATION�D PFIO PERTY UNE/ n LST STATION LJ E TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) ` LEACliNO UNE O.8 LENGTH OF UNEB ' ` S DISTANCE TO NEAREST:WELL FOUNDATION t"�0 PROPERTY UNE FILTER BED DTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 5EEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE /\ DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE eE IN CCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOMEOWNER OR LICENSED C IFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH / THIS PERMIT 1S ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNEB CT TO WOR(MAN'8 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IOF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO N8ATKIN LAWS OF CALIFORNIA.' THE APPLICANT MUSTDVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW.TITLE: DATE: - PL/T PLAN RA O SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING T E PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISP08AL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, G. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOI NO PROPERTY. ......... :.. .... ..... ..... .. .. po ....... .. .. . ... - .. _. . � .... .......... . ...................... ........................................... �,G� C' . .. ..._..! _ . ..:..._ .. a ... 0... p . ..... 7��30 xl�� `F'W,ppARTMENT USE ONLY APPLICATION ACCEPTED BY, /✓% DATE: ! > AREA: TANK,PIT OR SUMP INSPECTION BBy( DATE 1 / FINAL INSPECTION BY F''/ � Yom'" DATE ADDITIONAL COMMENTS: Ir - �lf�G'/� ACCOUNTING ONLY: AID/ FAC+F PE CODE FEE INTO AMOUNT REMITTED CIIECK,//CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE yzi 2y �;G� �� y-ov Pub.Health Serv.-Enviro.174(3/96)