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APPLICATION FOR LIQUID WASTE PERMIT SAw JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION +� 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Tripliub) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18A.1� COMPU C V TTVAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS IA/R_D(SS O,IF SAN JOAOVIN COUNTY PUBLIC HEALTH SS}ERR�VIC�ES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE68/OR APNI 10 J% "i "I'-, f�`y�� SCm �1-—N~T"y LOT 81ZEq� OWNER'S NAM G C7 r �, DRESS 1 0-: ✓� ` r— -T �✓_ PHONE R3 37�' IJ7 7 CONTRACTOR 'g A L Y'-�( ADDRES 1-- 13` U L� UCI Q PHONE -3 z) I SUBCONTRACTOR l/1/\ ADDRESS UCf u 390 PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDIUON ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(vI I I HOW MANY Applf edon I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOI /� RACIER: �} WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP X, [ITYPE/MFG l:D ^ P-CAPACITY ��j/L' NO.COM PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPS UNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) l LEACHING UNE ❑ NO.S LENGTH OF LINES -yam— DISTANCE TO NEAREST:WELL ,�FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PITS ADEPTH _SIZE NUMBER 2 DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMP$ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MTH SAN 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:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FORWHICH THIS PERMIT 18 ISSUED,1 8HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS 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 COM TION LAWS OF FO IA.' THMAM CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. "�7 ' TrTLE: SIGNED X DATE: PLOT PLAN(DRAW TO SCALE)SCALE_ to 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. 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. _._ .. _:......:........ - .......:.J.� .. :... ....:. .....:......;..... ......:......i.......:........ .. - .. .. .. n .. .. .. l� - � 1f .. :.. ................. ..... ... .. ..... .. x-11 .4. ........... . .........<...... ... ........................ ....:.....:...... .. . .:......:.. ..<... ..:... qb . . ...'......:..............:.. .. .. .. ......... .. .. .. ......:.....I........:.1- ............. ::;:.:: :°:::..:::.:.:::::.::::::.::.:...:::..... M oL f, r� . ..................... ............................................ ................... ....... ....:.. :::::::: :.: :....:.. ......:.. ....... :. ` ....°.... . ..... :.......... .:... ..:.... ..... ............... ..:... ..... .........:.....::...... .............:............<..... .. . AM ......... ........... ...... ...:..... :......:.. .. °.. ........ L ..............'.... ! �l ... FOR DEPARTMENT USE ONLY {/ APPLICATION ACCEPTED BY DATE: �/ AREA: 7—A4 TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE�Z ,6?1 ADDITIONAL COMMENTS: ACCOUNTING ONLY: RIO/ FAC# PE CODE FEE INFO AMOUNT REPA D HEC /CASH RECEIVED BY DATE SR/PERMIT NUMtER INVOICE 0 r Pub.Health Serv.-Enviro.174(3/96)