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APPLICATION FOR LIDUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRUM DATE ISSUED ICBmp6to In Triplie lol APPLICATION 18 HEREBY MADE TO THE BAN JOADUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 10 MADE IN COMPLIANCE WITH SAN JOAGUIN COUNTY DEVELOPM CTR /� E �N �T TITLE,CHAPTER 9-1110.3 AND THE STAN D ARD S OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. ✓ JOB ADDRESSOR APN/ / DMC/Y D CITY � �.% '.l�/V �� LOT S12E OWNER'S NAMEIVR79/.42-64& ice' ADDRESS r//� �( ✓��LJ%nF'�r�UN/''� �D,.�q- PHONE CONTRACTOR F'e.�i l/t �7._� ADDRE66��/ /211 �1_ 1y 7 anp UCI��SD� PHONE.2 5!� BUB CONTRACTOR ADDRESS LICI PHONE TYPE OF SEPTIC WORK: NEN INSTALLATON RUNR/AODITION❑ —I.i UCTDN❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) RAC TFATI.1 I I NOW MANY AFdlo�tlon/ INSTALLATION WILL SEINE RESIDENCE PL'• COMMERCIAL❑ OTHER❑ NUMBER OF WHO UNITS: NUIMEIM OF BEDROOMS:_NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 7 FELT: PrT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREABE TRAP 13TYPEMFO F)//-/ CAPACRYTD�07�.OL� NO.CDMPARTMENTS .�2- PKO TREATMENT PLANT❑DISTANCE TO NEAREST: WELL S� FOUNDATION S PROPERTY VNE I LIFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SVBTEMI p' y �+� f / LEACHING NNE 'r' NO.•LENGTH OF UNE• ,-.L- OG/�.� DISTANCE TO NEAREST:WELL FOUNDATION C7 r' PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE FITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPf ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OFTHE SAW JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFYTHAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'•COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB-CONTRACTIN0 SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PER60NB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-THE APPUCMT MUST CALL 28 HOURS IN ADVANCE FOR AyLL-REQUIRED INSPECTIONS.COMPLETE DRAWING BELOW. SIGNED X L/� + TITLE: V .GIQC/ ) DATE GGG��/ v PLOT RAN(DRAW TO SCALE)SCALE' -to A 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S.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 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. � ..... .. ......: ....... ... .. ..i._... .;... :......: _....: T � ............. .... :..... - J i .. . N1AY,1.a�9�8 kN J(OAL7UIN COUNTY` T FOR DEPARTMENT USE ONLY IDATE: / APPLICATION ACCEPTED BY 11 ASA: TANK,PR OR SUMP INSPECTION By'\ / FINAL INSPECTION BV - DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: NO/ FAC/ PE CODE FEE INFO AMOUNT REMI ITED CHEC IL ASH RECEIVED BY DATE SR/PEPNT NIIMBM INVOICE I Pub.HBBRh Serv.-Enviro.174(3/96) �`