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APPLICATION FOR LIQUID WASTE PERMIT SA.. JOAQUIN COUNTY PUBLIC HEALTH S. DICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CempNts In TFiplkStfl APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TRnI�,,14mAAPTER 9-1110.3 AND TlHEE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE•�S.ENVIRONMENTAL HEALTH DIVISION. / JOB ADDRESSIOR APNI L4 30V ! LI ,G V /ZO,Y - ! CITY �j�R-/!I nLOT BIZ'�'4C OWNER'S NAME ,fi-LAS Ii 91('e(EJ/V P �/ ADDRES8 /�'L/ I�� /Z25//V1D Li 12K' .J�/�� C- PHONE 11 �S-7631 CONTRACTOR VA 1,1- y Mi ,y t�G/J ADDRESS •�oX 379'4 7W'eI�� UCF PHONE 4C'/" �} SUB CONTRACTOR -� ADDRESS UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ / INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)1 I�HOW MANY INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LMNO UMTS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/BUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPEJMFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER LIED ❑WIDTH LENGTH 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 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 WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHK:H THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGN URE CERTIFIES T OLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENS N LAWFOF71A.* THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQGUIR ED INSPECTIONS. COMPLETE DRAWING BELOW. �}�y BIOMED X /� TITLE:�(1/0�'�'�- DATE: PLOT N(DRAW TO SCALE)SCALE'�II2 oy' f -Io 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDI 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. DIMEN81ONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. 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. - ..... .. .............. .. .. .. ...:......:. . ..... ". ... .. . ..... ... .. ... .. .. .. .. �. .. ..:......:. : . :. SEP-2119 ' :::.. ....Ts . 'vi JGAQUiN C()Ut..Y .._. ;....... . .. .. _ _. ....... .. PUBLIC HEALTH SERVICE' ........ .. .. clIVfi10NMENTAt.HE AI Pli DIVISIO . �. ................:...... ......<.............; EVER :. pa Y . .................. ............... ............. .... .. .. . ;.. ..............:.....;....'.. :..... .......'......`:............. .... .. ..... .. :... :.. ..:. ..:...... ........ ;.. ..:.. .....;.....:. .;.....:... .......:............;...................,......:......., .. ..'... ....... :.. ..<............>... ......... ..:............;........._. ........ .. .....,,..,�.. ..... ............ . ..:.. . ^ �� / . : ...... ........... :.....!�F/�!!V. .. ... _. ...... ...............:.... ................ . ............ .......... ..... ... ......... _... FOR DEDAPTMENT USE ONLY C DATE: q q AREA: APPLICATION ACCEPTED B - /� TANK,PT OR BUMP INSPECTION By ,Q DATE I I FINAL INSPECTION BY ✓ DATE ! ADDITIONAL COMMENTS: ACCOIlr/TINO ONLY: AID# FAC# PE CODE FEE INFO AMOUNT RBMITED CHE K/!C SH REC BY DATE SR/PEFWIIT NUIMBEi INVOICE! 17r.06 0 dao 9 �. FS 5Z Pub.Health Serv.-Enviro.174(3/96)