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V ,y,.s•.mr '� i� � 'y APPLICATION FOR LIQUID WASTE PERMIT WN JOAQUIN COUNTY PUBLIC HEALTH RVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 DM•REFUNDAE E PER1111F %FIRES YEAR FADM DA E ISSU1D k �,k: , ICompkts In TripIkata) a APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND.OR INSTALL THE WNOFrC DESCRIBED. THIS APPLICATION 18 MADE IN COMPIJ/ Fl BAN JOAOUIN:COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH BERVICES.E ENTAL HEALTH DIVISION. 77�''III LOT 812E JOB ADDRESS/OR ADN# ( PHONE S ::,I P r OWNER'S ADORES,NAME V\ L>C yyHONE t CONTRACTOR ADDRESS PRONE BUD CONTRACTOR ADDRESS # I F TYPE OF SEPTIC WORK: Ili NEW IN ❑ REPANVADDITION ❑ DEBTRUCTIO lif I PPRC TESTIia)I 1 HOW MANY (No SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) . '.� APPYa�tlen INSTALLATION WILL SEINE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ :I NUMBER OF UVING UNITS: NUMBER OF BEDROOMS: NUMB9R OF EMPLOYEE.): WATER TABLE DEFTH CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PRTI8UMF'BOIL CHARACTER: r SEPTIC TAMUaREASE TRAP ❑TYPEIMFO ;CAPACITY NO.COMPARTMENTS Pi TREATMENT PLANT 11DISTANCE TNEAREST: WELL %' FOUNDATION PROPERTY LINE �`l LIFT STATION❑ SIZE TYPE OF PUMP BAND OILJSEPARATOR(ENCLOSED SYSTEM) �+ DISTANCE LEACHING UNE 13 NO..ak'LENOTH�'OF LINES NCE TO NEAREST:WELLFOUNDATION PROPERTY Lv� ` INE v FILTER BED ❑WIDTH_" LENGTH DEPTH '� DISTANCE TO NEAREST-WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH - LENGTH DEPTH 't DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITA E3 DEPTH SIZE NUMBER I DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS $ ©WIUTH - .i LENGTH DEPTH _.,r DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL.PONDS ❑WIDTH ,I LENGTH DEPTH : DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY!CERTIFY THAT I 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 OF THE GAN JOAQUIN COUNTY.140ME OWNER OR LICENSED AGENT WONATURE CERTIFIES THE FOLLOWING.4 CERTIFYT14AT IN THE PERFORMANCE OF THE WQW FORWHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A$TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 IBSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'e COMPENSATION LAW F CALIFORNIA.' THE APPLICANT 70CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X � TITLE: - DATE: k i0 PLOT PLAN(DRAW TO SCALEI SCALE--to r 1. NAMED OF STREETS OR ADA68 NEAREST TO OR BOUNDING THE PROPERTY. a 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, G. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON - INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. p THE PROPERTY OR ADJOINING PROPERTY. ...i.....A .i.....:.......... .. _ .. .. - ......:.......'......i... ....,- ....... .... ......E ., - - l5 . . II fn I i .. .. ., .. .. .. .- ..:.. .�......i.... I, E - .:....:.......... .:....... ...... .. - .. !" G .. .... P .. ti9 ..:.._ 4 I { xFCES ......:....... t�Cfa l I'A�'f )4l (ON k C#ul§:.......:..... . ....:...............: . . .:............ ....:............. ;.............:...,..:.. :.....-:.. ...:,....i....... :. .. ....... ..:.. ...:.-... ..:......:......•....... .... .�.- 'rte FOR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY A Ap, '`I DATE: 17 AREA: TANK,PIT OR SUMP INSPECTION BY I� DATE FNAL INSPECTION BY DATE 1 t ADDITIONAL COMMENTS: �� )n, . 'Y ACCOUNTING ONLY: i' AID# FAC# ' k PE CIIDE FEE INFO ;' AMOUNT IFtiTTED CHEC ABH RECRVW BY DATE SR I PERMIT NUMBER INVOICE# (0 Sf Pub.Heakh Serv. Envlro.174(3/96)