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APPLICATION FOR LIQUID WASTE PERMIT LJU S— JOAQUIN COUNTY PUBLIC HEALTH AVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NOR-REFUNDARIE PERMIT EXPIRES t YEAR FROM DATE ISSUED ICampleta in TrlplieatFl APPLICATION IS HEREBY MADE TO THE BAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS AP0.ICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOP./M)�ENT TIRLL CNIAA.PEER 99-11110.3/)AND THE STANDARDS OF SAN"AMIN COUNTY PUBLIC HEALTH SE/R-VICES.�/ENVIRONMENTAL HEALTH N"WN. JOB ADDRESIVOPI AM# /✓-IOL ""asp•46:�t / i (J �-T r ',,/ )CITY '�"TL'/>'�r��" LOT SIZE_ OWNER-9 NAME�1 A✓ ADDRESS /�tM `' //UCl3 h.-S40-sV o RIONE 7 s VY,d I-O CGNIRADTDR�)� ad CN�JPLL:�< ADDRESSII7 St BU9 CONTRACTOR ADDRESS UC' PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPARVADDITION ❑ DESTRUCTIO (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PRIC TESTIER 1 1 HOW MANY APpilwaen I INSTALLATION WILL ERNE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LMNO UNITS:_ NUMBER OF SEDROOMa: NUMBER OF EMROYETI: CHARACTER OF SOLI TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABU DEPTH {ERIC TANIUGIIEASE TMP ❑TYPE/RAFG CAPACITY NO.COMPARTMENTS - WO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF FUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING ONE ❑ NO.S LENGTH OF ONES DISTANCE TO NEAREST:WELLFOUNDATION FROPERTY LAVE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION R FERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY ME SEEPAGE HTB ❑DEFTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY ONE DISPOSAL FONDS ❑WIDTH LENOTN DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE - I HERESY 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 OF THE SAN"AMIN COUNTY.HOME OWNEROR LICENSED AGENT-6 SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IBSUED.1 SHALL NOT EMPLOY ANY FERSLIN M SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRNG OR SUB-CONTRACTING EIUNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSLND,1 SHALL EMPLOY PERSONS SUBJECT TO WONKMAN•B COMPENSATION TAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 34 HOURa IN ADVANCE FOR ALL MOUIRED INS,PJEClTIOgNn�S.. COMPLETE DIAWNG BIBURAL C�` SIONED X� "'Y Y TIT U:(Ii� r/ jt� fa.l /GW^Or.vS DATE: 1_,2!—C / ROT RAN)DRAW TO SCALE)SCALE_ -la 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISIOSAL 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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY ON INCLUNNO CONKED AREAS SUCH AS PATIOS,dSVEWAYS,AND WALKS. THE FROPERTY OR ADJOINING F RDMM- L.J 1. i... .. . ......... .b...... v 1 .. CC l / ............ �y 5 � J GA+P/l IIv j TL'✓v ... r `L� �Y�d �