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APPLICATION FOR LIQUID WASTE PERMIT E SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t/ L N D LA,5-& ENVIRONMENTAL HEALTH DIVISION 1907 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 r _ 4 IION•REFUNDADIE PERMIT EXPIOES I YEAH FROM DATE ISSUED ICSIEpittf In TriplWtt} APPLICATION 18 HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. TWO APPLICATION IS MADE M COMPLIANCE WITH SAN JOAGUN COUNTY DEVELOPMENT TITRE CHAPTER 9-t 1 1 O. AND THE A�bARDS S JOAOUIN COUNTY PUBVC NEJILTN S[�/�-y'1�CTELS. NMENTAI HEALTH DIVINON. 11 -- . �/ CITY Lar 812V�� / JOB AOOIIE 88/OR AR?f OLMJER'S NAMEGA AD[M1ES8_/�' CONTRACTOR ADDRESS L)Cf PONE � SUB CONTRACTORLIC �� /1�i -'""'�f ADDRESS % PNONEu3 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPNIU [IIT DESTmicnoN ❑ NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAIIABLJ:WITHIN 200 FEET OF BEADING.) POW TESTI•I( 1 HOW MANY �� 1�I f App*—"" INSTALLATION WILL SERVE: RESIDENCE ElCOMMERCIAL 13OTHER 4( Lw26 NUMBER Of LIVINO UNITS: NUMBEROF EDROOMS: .1c. OF 9AROYlu: 00 I EA OF 801L TO A DEPTH Of 3 FEET: PITSOS.CHARACTEA:A�E � WATER TABLE DEPTH 1 '� K/0/IEASE TRAP' ❑TYPE/MFa''1C. "n"�� R CAPACY I " NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NZA RBST: WELL(m D 71 FOUNDATIONS_ PROPERTY LINE f UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.a LENGTH OF LINER DWANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER BED ❑WIDTH UENOTN Of"" 018TANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOULDED �❑(WIDTH LENGTH DEPTH DISTANCE TO NEAMBT:WELL FOUNDATION PROPERTY LINE >L SUPAOS FITS DIFTH�out.3 1 NUMBER �3 DISTAME TO NEAREST:V.EL�I�d� FOUNDATION %� t PFonwrY UNE SUMP /❑'WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL FONDS ❑WIDTH LENGTH DEPTH D18TA A TO NEAREST:WELL FOUNDATION PROPERTY UNE 1 HERESY CERTIFY THAT 1 HAVE PREP -0 THIS APPLICATION AND THAT THE WOAC WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND IIEODUATIONSOFTHE SAN JOA NCOUNTY.HOMEOWNERORLICENSEDAGENT'SSIGNATURECERTIMSTHEFOLLOW0IO:*ICEIRTIFYTHATINTHEPEiiOFMANCEOFTHEWORKFORIMKH THIS P'[RMI1 '0= I SHALL NOT PLOY ANY PERSON N SUCH A MANNER AB TO BECOME BU&JECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA.' CONTRACTOR'S HIRM OR ►10 NATIVE CERT IEB THE fOLLOWINO: •T CERTIFY THAT N TIE PERFORMANCE Of THE WORK FOR WHICH THIB PERMIT If ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO RL C S ION LAWS C FORM - THE APPLICANT MUST CALL 24 HOURS IN ADEG VANCE FOR ALL RW"INS►EATIONS. COMPLETE DRAWING BELOW. r� (7� Ox TITLE: �V�_ DATE: PILOT PLN IDKAW TO SCALLEI SCALE ` 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE P"OPfKry. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OVTLNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. �y 3. DIMENSIONED OUTLINES AND LOCATION OF ALL"ISITINO AND PROPOSED STRUCTURES. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HOREO I FT.ON UN WLUOWO COVERED AREAS MXJ A8 PATIOS,DRIVEWAYS.AND WALK&. THE PROPERTY OR ADJOINING PROPERTY. A!.. .. :.... ... ....:. . r Q� ............:... Y . ............ ..:... i Lel' �Pp ; NS ps \0v% N...A..n-..•�.C....r; , 1,fIIc� . L� •M I.,.. ..•, M Q -, p��v N N .....a...._.._. _ — ♦ Z„0,N,'raw� Elf (` IL •...,_...�fans/ ` .....o..... ....... i ' 1 r.lr a•..••r�' (hA•l lwt Wra�. 1. 4•• r..r,,..• I , ►,::'i: . 1•rt..,t/ /TIt"a'I-DIA•,r•To tn••aa i •r...a a..... .: ,f, �•`w.. �.��___ ��:.i.,...�rH r.V ma`s ILO Na.IL rf To- .... •: w. , 1 ...:......_._....... .._... c.atinwl• �R P.w+•. r..r pla..•♦aM..�. .. LL11.� FOR AFTMOIT USE ONLY APPLICATION ACCEPTED BY i DATE: / " AREA: z� OR BUMP[NSPECTION By 'f�, - DATE I FINAL INSPECTION BY G DATE / !"Ce ADDITIONAL COMMENT$: \ ACCOURTMO ONLY: AIDO ` FACE P COOL FEE INFOAMOUNT FAMITED CHE7C !CASH R SNm IC IV DATE $A I POWAT NUMBER INVOICE f is ZSZ� 0 i6-75- nd Pub.Health Serv.-Env)ro.174(3/96)