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APPLICATION FOR LIQUID WASTE PERMI` SAN JOAQUIN COUNTY PUBLIC HEAL.. SERVICE ENVIRONMENTAL HEALTH DIVISION opy 304 EAST WEBER AVENUE, STOCKTON, CA 9520C (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complate In Tripikate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION 18 MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT ��J(�TLE.CHAPTER 9-1110.3 AND THE STANDARDS yOF SAN JOAQUIN COOUNTY�BLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. CJS ) JOB ADDRESSOR APPN1/ % A� / A/ ° �U/lJl�� "tel, CITY w�-� LOT SIZE O�hcry(-��,T OWNER'S NAME �/' K-�y /✓/ "/7�? ADDRESS /�' `�-' PHONE v_ v gv`) CONTRACTOR /ADDRESS IJC PHONE //' acs ,// SUBCONTRACTOR �/�� f LADDRE6S UC/ PHONE v.J �T TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIPJADDITION Cl DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN TOO FEET OF BUILDING.) PERC TESTI)L 1 HOW MANY P_ APPNo don- INSTALLATION WILL SERVE: RESIDENCE 11COMMERCIAL ❑ OTHEf� U !/( NUMBER OF LIVING UMTS: NUMBER OF BEDDRO,.O'MS: NUMBER OF EMPLOYEES: CH R OF SOIL TO A DEPTH OF 3 FEET:GB `��,�,L�- GFITISUMP SOIL CHARACTER: / WATER TABLE DEPTH C T K/OREASE TRAP ❑TVPE/MFOy/�v 51U� CAPACrTY /6,0 ¢� NO.COMPARTMENTS .t EAPLANT ANT 11DISTANCE TO NEAREST: WELL�_� FOUNDATION— lPROPERTY UNE V A 7- 1 STATION�kEO. TYPE OF PV P SAND OIL SEPARATOR(ENCLOSED SYSTEM)LEACHING UNE S LENGTH OF UNE:F ",V-:—. DISTANCE TO NEAREST:WEuf 5 o FOUNDATION 20 PROPERTY UNE FILTER BED DTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE ATS ❑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 I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW(WILL BE GONE INCCORDANCE WTTH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIONAT C IFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT iS ISSUED,I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO B C BU CT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE ANC I OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO NSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST I ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X �/ TITLE: GATE: PIXT PLA6ROFY11EITI-Y. TO SCALE)SCALE_ 'I. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING T 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 ADJOI NO PROPERTY. '... .;.. P .. 1� __........:.. ............ ........ ................. .. .. .. .... ......... .. . .. ;. ............................... 1 ....... .. :... ........... ........ .. ....... . .. .; ... .. ...... .. ............... .... ' 7s• 5 ..:.............;. ..`.. ........ �s o.?� Lu.µ .. r ;. ...;.... : ..........:............ . ..:.. ......... .:. 0 ..... _. ..... .......:..... . . a � e . ....... . ....... . L .�...... : .... _. r' . . .. . //J 9 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYa�A//�✓6-4 DATE: z O�� V4 AREA' TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY /L�� S'�' DATE / / 9/CV ADDITIONAL COMMENTS:1L r7/L tf � / , (jf�C,4, f/n-e.5 19-C- 41d ZI/7 Cv�.t� J% % fj/y1 t,/ 6",Y�'lif5 ACCOUNTING ONLY: IUD# FAC/ PE CODE FEE INFO AMOUNT RFMIITED CHECKI/CASH RECETVED BY DATE SR/P9WMT NUMSER INVOICE Pub.Health Serv.-Enviro.174(3/96)