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APPLICATION FOR LIQUID WASTE FIR T PAYMENT SA.4 JOAQUIN COUNTY PUBLIC HTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 SEP 2 1 2000 (209)468-3420 SAN JOAQUIN COUNTY NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC HEALTH SERVICES ICompleta In Triplicate) ENVIRONMENTAL HEALTH DIVISION APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATKIN 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,TITTLE,CHAPTEnR 9-1110.3�A.N}-D�THE I/STANDARDS OF S/ANN JOAOUN COUNTY PUBLIC HEALTH SERVICES,1ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESB/OR APN/ , , ' )I C7 nK� Q I�Lv/1 • 1 l I l 6j C L L\G�1 J `�I q /"�,^CIITY��r��n Cl Y 1' `12 l) �f/ LOT SIZE Iq OWNER'S NAME Y 11 1 1n7/LA V -L i V 11/�J� \ ADDRESS ^`EIA _�& li'(Y'nf l D P- - Q�-Y ,�,^/PHONE W CONTRACTOR P.I 1 11.IY.� .N 1 �/-C`J� ADDRESS L 1'�• I,�� f , '��I� LK:I"w 444p("I PHONE SUB CONTRACTOR ADDRESS uC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ ,,L IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTY)IJP HOW MANY Z- Applimdon INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER❑ NUMBER OF WINO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE PTH SEPTIC TANK/ORFASE TMP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.6 LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE ATS ❑DEPTHSIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND 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 THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrT 18 ISSUED,1 SHALL 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:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPE /LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL LRREQUIRED SIINNSPECTION& COMPLETE DRAWING /y+BELOW. SIGNED X `� - TITLE: �al<ff t `amu DATE: r y PLOT PLAN(DRAW TO SCALE)SCALE_ 'to l` 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, 6. 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. ....:...............:.......................... ......... - .............. ....;...........:............,......;......:.....: .. .... .. .. .. ......... ...... .. ....... .. .. .. .. .. .. \ ........:.................................:....;..... ..... ..... ..;.....:..... :... ..:......:... ` _. .......:.....:........ ......................,.....:.....:..... .. .. .......... ... ... ..f_...:... ; . .:. _.:_....,......:......:......:.....:..........................;...... ... ..;..... .:.....:... . ... .'......i......1.....i.............i..... .. .. .. _....... .. .. .. .. .. ....:.... ........:.... .. . :.. .:.. ..;......:.... .:......:.....:..... . _ . : _ - ..... ........................:......;.................. . .. - .._......i.... .... .. .. .. .... ................. .....:.............:............... :..........:....:.. . .. �� ..... a ...... ..........._....... ... ..:.............: : ...:..............:..............:..............:... .. . .............: j __ :..:..:.:::.:.:.- . ... .............................. ;.......... .... . ..... ...... ... .. ......... ....... ..................................... ... .Z ..... ...... .. . _... :... ..:......>.. .: ..:...�1 .......:...... . :............:............. ` Y. . . . . . .. ......... ........>.. .....'L .. .. .. ............... ............. ::... .............. l�acv� :. :::::. .::.::.::::.: ...... .. ...... :::: : : ft _ ... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY� GATE: AREA: iQt27 TANK,AT OR SUMP INSPECTION BY DATE ! ! FINAL INSPECTION BY DATE ! ADDITIONAL COMMENTS:�! '� J / / G2, tz (? ACCOUNTING ONLY: AID/ FAC:r P£CODE FEE INFO AMOUNT RUMITED CIIECKI/CASH RECEIVED BY DATE �) SA/PERT NUMBER INVOICE/ t-1 (/ Pub.Health Serv.-Enviro.174(3/96)