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PPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SOCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 .,i (209) 468.3420 ... i NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATKTN 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER/9-1110.3 ANDTHE STANDARDSOFSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL /HEALTH DIVISION. JOB ADDRESSOR APN/ I(�O �V `-'I/e✓Yle h f S ��...�r U I 1 I/O'O'2 I C1rTY Cl S WI e. 1�S . tom- �- LOT SIZE OWNER'S NAME �Q hQ(� J` I C�1 r ADDRESS PPQA 39�r9 6l'eMeO/ I , f��Qyn,- I PHONE � 4 N le CQ1^N C� C Iv ,'t"C ADDRESS 5 5 (�1966 1 Mcz i cG " LIC, L S-37 PHONE q'3 SUB CONTRACTOR ADDRESS I�GIL"., l.0. I S2'I� UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRUADDITION ❑ DESTRUCTION ❑ [NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIS)I I HOW MANY 2 Appilmdon# INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ /� C I NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: L ' ' / y / L CHARACTER OF SOIL TO A DEPTH OF I FEET: s ed_PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ❑TYPE/MFG CAPACrTY 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 ❑ NO.•LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BUMPS ❑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 SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER ORUCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. r v i -�u� DATE: �IGNED X - TITLE: T�—�' PLOT PLAN(DRAW TO SCALE)SCALE-- 10 V 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. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, E. 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. .i......:......:.......:........................................... ..............:_... :.............'........................... :.......; _. c.....'.............: ......... .. .. ^ `J / ......:.............................:.............. :......:.......:............... :...... ._ _... SpKt,:•.X00• ......:.......:.......i......L...................... we .................................. .. of , ..... ........................_................ ....... ra-cN p i ...........:.............:....... ............... I....> C) �c. n A. c.� . �'1Y. ........... . w +Ilona .. , .. ��' ��► ...:.............. 1,M'0 MR' .. ...... S.1N JUAQUIN COUNTY :.... . ..PUBLIC HEALTH HE,LrH j V S ........... ......... ............:.............:...................:.... . FO DEPAR T USE ONLY 06 AREA: APPLICATION ACCEPTED By DATE: (Z TANK,PIT OR SUMP INSPECTION BY q l' DATE ! / FINAL INSPECTION BY DATE ! / ADDITIONAL COMMENTS: �L/�C-�-✓ {�f ACCOUNTING ONLY: AID# FACT PE CODE FEE INFO AMOUNT RMMITED CHEC ASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE I Pub,Health Serv.-Enviro.174(3/96)