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APPLICATION FOR LIQUID WASTE PERMIT Swl JOAQUIN COUNTY PUBLIC HEALTH S. /ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complata In Triplicate) APPLICATION 19 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. ? JOB ADDRES8/On APNF /13 3p( ,{J./l.-14 r/�Jy��yG��-�'!'. Crry U9/r7/�// LOpT 812EJ OWNER'S NAME '!,1 )/�'IPjff A7—34Q/V/ C 10AF`C-l/ADDRESS I(�/b�d Sj S JACK�NE• .9� PHONE s / (/—Q 4�p2g CONTRACTOR U/'+�LEy /1�Ly Zee ��/�C/� ADDRESS -P, fi'DSC 37'Y4- 7UP-40 ifje UCE PHONE T SUB CONTRACTOR ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ / IND SEPTIC SYSTEM PERMITTED IF PUSUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(.)1�I HOW MANY Appll adon 9 INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LPANO UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTI4 OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING UNE ❑ N0.A LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BUMPS ❑%MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORUCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIO TURE CT:RTIFIE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPS ION LAWS O IA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. Q SIGNED X q TIT LE: Oki*FE2 DATE: PLOT N(DRAW TO SCALE)SCALE'�V 5441-, `/to 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 OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALRB. THE PROPERTY OR ADJOINING PROPERTY. __ `...... ... ..... ..........................;.......,......;..... :......, ... __ _ ...:.... .. ....... :......: "� :.. .:. ..... .. 0199 f .. N OU HEALTH SFRVICE5 O ... ...... � � �IiBL t T41L VI. V F _HEALTH OIVISIUN .......:........... ...... ......... ........................ ...... .. ............ ........ . ;. .....,...... _. /�aus� ...... ....:.... .�Tui�P..... ...,�....`.......:..... .: ........... ................ ......... ...... ��c ....... :.....:....... .......>.............;......;..... ...... �E .. ...... ..... _...... .... .......... .. .. :.. . :.... ............ ...................:.. ................................41:,......,.......... _......._..............:.............;.............:............ ....�.. . .... . ..... .. ... ..... ..... Ai ..W�.6�,.. . . .. <... .............................:......:.._..... ...... DESfe7NA D..... :..... .. MaI��E . .:.. .........:.... ..... ...... ..... ....... .. .....:... ..... .. . . ... ... ............ _. . ................... Q FOR DEPARTMENT USE ONLY 1 r^o AREA: APPLICATION ACCEPTED BY 4 /,4 A O DATE: ,, DATE / / FINAL INSPECTION BY TE / Z TANK,PIT OR SUMP INSPECTION B ADDITIONAL COMMENTS:_ 2 2� ACCOUNTING ONLY: AIDS PE CODE FEE INFO AMOUNT RETMIITED CHECK ASH RECEIVED BY DATE an/PERMIT NUNISER INVOICE f z22I I 5,4.06 -o ao ©ar>S Pub.Health Serv.-Enviro.174(3/96)