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� 4 APPLICATION FOR LIQUID 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 I YEAR FROM DATE ISSUED / (Complete In Triplieats) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVIBK)N. JOB ADDRESB/OR APN/ / i QS /D11141Y1,1 TY .TT� JLOTSIZE46� -11 OWNER'S NAME '/ ADDRESS -w—, PHONE pj� - 7 /O3 CONTRACTOR 2,v- DDRESS 12 1,,C' LICE PHONE SUB CONTRACTOR ADDRESS UCS PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ® DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)1 1 HOW MANY AppNmdon S INSTALLATION WILL SERVE: RESIDENCE P COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS:_ NUMBER OF A�GM NUMBER OF EMPLOYEES(:, CHARACTER OF SOIL TO A DEPTH OF 0 FEET: PIT/SUMP SOIL CHAPACTER: f�� W/7/�J1y /WATER TABLE DEPTH /bO/ SEPTIC TANK/OREASE TRAP ❑TYPE/MFOA/G - CAPACITY /Z/1O L-'l4-1, NO.COMPARTMENTS y� PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL SO FOUNDATION / V/ PROPERTY LINE ✓C/ / LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) p LEACHING UNE Pd NO.•LENGTH OF LINES z- /U ( 4 6 DISTANCE TO NEAREST:WELL Z& FOUNDATIONy7^ PROPERTY UNE--'V/ FILTER SED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH_DEPTH DISTANCE TO NEAREST:WELL r FOUNDATION PROPERTY UNE SEEPAGE ATS DEPTH ZS SIZE- 91 NUMBER_ DISTANCE TO NEAREST:WELL �•>a FOUNDATION J// PROPERTY LINE BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HE ERTIFY THAT I HAVE PREPARED THIS PPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES 1 AN REGU TIONS OF THE N JOAQUIN COV .HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WO FK FOR WHICH THI PERM 91 D, BHA NOT EMPLOY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB CONTRA TI SIO ATU RTIFIES THE LO . 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WO AN'S PE OF CALL THE APPUCA T MUST LL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. ` ^ ZED X TITLE: \ ' DATE: PLOT PLAN(DRAW TO SCALE)SCALE_ Io 1. NAMES OFST S 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, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALJKS. THE PROPERTY OR ADJOINING PROPERTY. I ... .:. . ....:.. .: . .... . . .... .. __ , ...... ......( .... .. u ., . . . -ARS .:............:.. :... .............:. ... _ .. _.. _ ... ... . Wl+on.J .................:.......€.....: ..; .........;.......... .. _ ........ ... .. ... ' ...:.......;.....:......;..... ,� <..... ry w >G ......;.....;.. 0 M :... _ .. .:.......:......:.......,......`.��1....(....................................... N �.Ivoo 4,�1. ./A�u ... .......... ....... . _.......;............<...... .. .. _ .. .. ................... ....................... . �.... _:R .. --:- X17 .......:.............:.......:.........................:............. .. !...�................'� �1 .,...............................................................................................................;:............ :.......:.........................,.................:.............°...... ct,a;� .. ......... . :� INt— .. ;.. ..:..... .... ..........,.................;......................... ..... ........:......:.......;.....:..�...;......:.............:... ..— .. .. .. ' . ........ ///n FORD APTMENT USE ONLYAPPLICATION ACCEPTED ACCEPTED BY �1 1 DATE: / ✓ [ / AREA: / TANK,rl'OR SUMP INSPECTION BY ATE K// NAL INSPECTION BY� // � E� ADDITIONAL COMMENTS: � ACCOUNTING ONLY: AID# FACT PE CODE FEE INFO AMO NT REMIITED CHEC ABH RECELVED BY DATE SR/PERWRT NUMBER INVOICE S /Z/ l� 3 GzaSo�' Pub.Health Serv.-Enviro.174(3/96)