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I y APPLICATION FOR LIQU10 WASTE PERMIT SAN JOAaUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION - P.O. BOX 388, 4461. SAN JOAQUIN ST., STOCKTON, CA 96201 0388 {209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUE ��-�,3Gt cYC7 r lComplete in Triplicate) Application is hereby made to the San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health Services, Environmental` - on. p 9S�Z�] �--• `. Job Address/or APN# --!! Q qqi �e� 0►8 4" �Z" Cit hTF�S Lot Size 7 "_ d Owner's Namef? �TZ Address �� r� >r �iS�7Phone � Contractor " Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION[1 DESTRUCTION[1 PERC TEST{ei L Now man; -- (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) �. 3_'Q s f� ♦ land Use Application! - Installation will serve: Residence X Commercial Other Qv- /oca l7 l .70cl� S Number of living units: Number of bedroom@: Number of employes: Character of soil to a depth of 3 feet: Pit/Sump SOIL Character: Water Table Depth SEPTIC TANKIGREASE TRAP ❑ Type/Mfg apacft No. Compartments PKG TREATMENT PLANT [ I Distance to nearest. Well Foundation Property line I' LIFT STATION[] Size Type of Pune Sand Oil Separator (elw ji�a gem) � LEACHING LINE [] No. & length of lines Distance to Nearest: Well Fo n Rroperty Lire [r1 FILTER RED [] Width Length 'A Depth " " Well Foj�'��aoperty Line Ef MOUNDED [] Width Length Depth " " Well AFpuri�a�tirn coperty Line�� E '�v JJUV UIN �< SEEPAGE PITS 0.. Depth Size Number 61 Well PQSMR �bi f�f7(� o rty Line s SUMPS [] Width Length -Elepth '+ " Welk U(kid$ �i Li�;+WW$y Line ^•.�-z DISPOSAL PONDS 13 Width Length Depth Well Foundation Property Line f I hereby certify that I have prepared this application and that the work wit be done in accordance with Sen 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 "I certify that in the performance of the work for which this.permit is issued, I shat!not-emptby'any person "in such a manner a to become subject to workman' ,Laws, ;.of-:compensation,LawaofYCaliforrii"a:"",Contractor's hiring or sub-contracting signature certifies the following: "I certify that. in`the performance of the work for which this permit is issued, I shall employ persons subject to workman'*` compe "ation laws of California.,, The applicant must call 24 baits in advance for all req ui red Inspection@. _Complete drawing below. Signed X TitG>er9/-Ir/_�JL�LI�j Date• "��'• PLOT PLAN (Draw to Scale) Scale—II to� t 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal systenior� 2. outline of.the property, with dimensions and North direction. proposed expansion of sewage disposel syate 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. n structures, including covered areas such as patios, driveways, fl the property or adjoining property. and walks. ¢� V RpuTE N� - J Yl e gW A r Eo�� Bay U D fff �s1 TAT C I I PtE a ! Q i' ~PA k PA n • N a e, FOR DEPARTMENT USE ONLY Application Accepted by ti te: re - Tank,�Pi.t-or Sump.lnsRectian by _ Date / ' / " Final Inspection by Date 1 1 Addtional" Comments:- L1 + ACCOUNTING ONLY. AID# FAC# G� I PE CODE FEE INFO AMOUNT REMITTED CHECKI)CASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE x a �3 F v 3 30 o«ass -