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jAPPLICATION FOR LIQUID WASTE PERMIT % "AN JOAQUIN COUNTY PUBLIC HEALTr-SERVICES ENVIRONMENTAL HEALTH DIVISION �e 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 46&3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PEP.MIT TO CONSTRUCT AND/OR INSTAR THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT T LE,CHAPTER 9-11 10.3 AND T11 S\TTANDARDS OF SAN JOAQUIN OUKTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. v JOB ADORE68/ORRA�APNI^n I `/� \ L..��)I/C � CITY `-10 'Ll� OWNER'S NAME�./'lX1i�L,L/L S ADDRESS 1�11q ` k `,LOT'- v FEIGNS��w �/��'J 0 CONTRACTOR ADDRESS UC# PHONE SUS CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ptd IND SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST()I 1 HOW MANY _ APpb-ti..I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALS OTHER�J gf' NUMBER OF WINO UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ' CHARACTER OF SOIL TO A DEPTH OF 3 FLET: ACkt-- 0 Q V PIT/SUMP SOIL CHARACTER: ! WATER TABLE DEPTH TIC TAN EASE TRAP ❑TYPE/M FG (•7 L'LC Wim++-�, CAPACITY ( (00 NO.COMPARTMENTS -C � PUNT❑ DISTANCE TO NEAREST: WELL I dU FOUNDATION O PROPERTY LINE OO LIFT STATION❑ SIZE TYPE OF PUMP SAND OSI.SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE Ir-NO.S LENGTH OF LINES /00' A A P 5 DISTANCE TO NEAREST:WELL G� � FOUNDATION ' I O�'PROPERTTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE V SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION _PROPERTY UNE i. DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE vL 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 OFTHESAN JOAQUINCOUNTY.HOME OWNERORUCENSED AGENT'S SIGNATURE CERTIFIESTHE FOLLOWING:'10ERTIFYTHAT INTHEPERFORMANCE OF THE WORK FOR WHICH / THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR \� SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO , WORKMAN'S COMPENSATION LAWS OF CACU�FORWIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X - `� /-2 TITLE: DATE �I PLOT PLAN(DRAW TO SCALE)SCALE [o ~t 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. .............. .............._. ... .............._.._ l L' 2� t , c � .. . ..... of . ......:......:......<. �` .......... a a ...... ........ .. .. ...;... .... . ... ............ . rz .. _ .. . ................. .. . ... . . , ...... . ...... .... to p ,,,n FOR DEPARTMENT USE ONLY �y IC�.I/G✓/'IX A / T/� � DATE: AREA: APPLICATION ACCEPTED t�Y - - Y1 ��f'1/J'��/ DATE l � O I 00 TANK,RT OR SUMP INSPECTION BY DATE / / FIN AL/I�dSP/ECTION B��,� r �� ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FACT PE CODE FEE INFO AMOUNT REIJBITED II /CASH RECEIVED BY DATE SR I P£RMIT NUMBER INVOICE I 2-1 Pub.Health Serv.-Enviro.174(3/96)