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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 85201-0388 8091 488.3420 NON-REFUNDARE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICanpi$11$in Tripll$st$1 APPLCAI-10N IS HEREBY MADE TO THE SAN JOAOMVIN COUNTY FOR A PERPMT TO CONSTRUCT ANOpR INSTALL THE WORK DESCRIBED- THIS APPUCATFON tS MADE IN COMR.IANCE WITH SAN JOAOUW COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 110.3 AND THE STANDAj/PRS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENV1gj,M,ENTAL HEALTH DIVNION. JOB ADDRESS,VR APTLYf/' i 1 0 1 V b� •�� -CITY v�-�t•lV� LOT SQ'E� ) OWNER'S NAME l�Cl `Y ADDRESS �Q1),O^q, IG�-1 11C � &�/yr CONTRACTOR ADDRESS--3 f 70 IN�[• W Y SUB CONTRACTOR_ ADDRESS LICS PPiONE TYPE OF SVM WORK: NEW INSTALLATtow IIQAIRIADdT13N ❑ DESTRUICTION❑ iNO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WRHIIN 200 FEET OF BU4DING.1 FDIC TwTMI 1 1 HIOW MANY AEIPSoHbn i 1N$TALLATION WILL awvt: RESIDENCE bl COMMERCIAL [3OTHER 13NUMBER OF WINO UNITB:.— NUMBER OFD NIB: NUMM OF OWW VEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: & PrTfSUMP SOIL CHARACTER: 1 WATER TABLE DEPTH y SEPTIC TANKIORE"K TRAP CAPACITY t�U L� NO.COMPMTMINTS h. FKG TREAT11 OT RANT%DISTANCE TO NEAREST: --SAZ!i- FOUNDATION� PROPERTY LINE UFT STATION❑ SIZE T\'PE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI _ LEACkEW UNE it NO.m LENGTH OF LINES ItQ9 DISTANCE TO NEAREST:WELL FOUNDAYION PROPERTY LINE FILTER DED ❑WIDTH LENGI-H DEPTH DISTANCE TO NEAREST:WELL FOUNiATION PROPERTY UNE 1' MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROP'ERT'Y INE �n S� 6L AOE FIT$ DEPTH- SIZE L L NUMBER=DISTANCE TO NEARE6f:WELL��FOUNDATION `+' PROPERTY WE S. SUNBS ❑WIDTH LENGTHDEPTH DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY LINE d\\l DISPOSAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THEFOLLOWiNO:•I CERTIFY THAT IN THEPERFORMANCE OF THE WORK FORWWH f THIS PERMIT IS ISSUED,I NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING 81 T CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PER MIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM ATIO WS OF CAUFORNIA.' HE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL:tEOURED INSPECTIONS. COMPLETE DRAWING BELOW. r SIGNED X TITLE:_ C�~O DATE: i PLOT RAN(DRAW TO SCAIJ:I SCALE _'to S 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL.SYSTEM OR PROPOSE + 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIENNONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTL RES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUMO COVERED AREAS SUCH AS PATK)S,DRWEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PRDFHRY- ..... .. ......:..._ .... .. ......... ... ... .. -................... .... .. ... .,.. ............ .... ."' ... .. . , _ .. y... .... .. ... ...w ...... .�.y.. ...{ ..!......... ....... .•.5. ..{... ...p......' .. ..... ...........6..... 7 I �Al j _ till V s b { ......b ...- ° .- ....... .. .. ............... ...-. ... ... 5 ....., 4996 'r { ............ ...'.. ... ........ .. ..... ;.iL.fy.��- ............ y ....'v a - . •..rIU VIRO�L�C� NhMENTAI. !EA FOR DEPARTMENT USE ONLY