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I Ut`t ,,APPLICATION FOR LIQUID WASTE PEIRMIT -JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 9520188 (209) 468.3420 i� (C(D NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUEDICamplets in TripReatel ii APPLICATION 18 HEREBY MAGE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DC06RIIIEM THIS AppUCATION IS MADE 114 COMPLIANCE M444 SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH BERVlCEQ,ENVIRON F.9VrAl HEALTH DIVISION, JOB ADDRESS/OR APN# 1611 -71 CfTY LOT SIZE E { OWNER'S NAME r--• yy�. � 4,j, ADDRER9 !' - Y PHONE ��f 1 CONTRACTOR �f7N�T ADDRESS +� ' —1 LIC#L3 pHDNE�� r y 1 i 6VR CONTRACTOR ADDRESS - Ii ,a LIct "Y— PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPMRIADbITION �� UFJII'RUCTION ❑ - IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEINER 18 AVAn-ASLE WITHIN 200 FEET OF RUILDINO.► ? PERC TEST(q)t 1 LLDW MANY , / - Apppeenen 7 INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL © OTHER❑ ,f { NUMBER OF LIVING UNITS: NUMBER OF BEDRODMB: NUMRFA OF EMPLOYEEI: I CHARACTER OF SOIL TO A DEPS'"Of 3 FEET: PITISUMP BOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIORFARE TRAP ❑TYPEIMFG CAPACITY NO.COMPARTMENTS 7--� PKO TRFATIVCNT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYBTEMI I - T LEACHlNO UNE NO.b LENGTH OP LINER .. i DISTANCE TO NEAREST:WELL TION-/— PROPERTY LINE FILTER BED ❑WIDTH �_ - �. LENOTIf DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED 0 WIDTH LENOTII �.,r ,„ _DEPTH DISTANCE TO NEAREST:WELD ` ��' s FOUNDATION r PROPERTY LINE `f TEPA—OE pLT� ❑DEPTH T 812E NUMREFI ! DISTANCE TO NEAREST:W£Ll`� 1�/�1TION�_PROPERTY LINE ". SUMPS 11 WlbtH L CNGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ti DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOrK W]LL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND 97117E LAWS,AND nUlE9 AND REGULATIONS OF THE CAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'1 CEATIFYTHAT INTHE PERFORMANCE OF THE WORK Fon W11t H THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOFKMAN'Q COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING O \ r!' SUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOA WHICH THIS PERMIT 18 18BUED,1 SHALL EMPLOY PERSONS SUBJECT TO q WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOLSRED ill"PECT10Ra. COMPLETE ORAWINO BELOW. v SIGNED X TITLE: BATE: i. PLOT PLAN{DRAW TO SCALE]SCALE 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, ,4. LOCATION OF HOUSE SEWAGE DISPOSAL SV EIu�OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE WACIEDISPOAI SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EX19TINO AND PROPOSED STRUCTURES, 6, LOCATION OF WELLS WITHIN RADIUS TONE HUNDRED FIFTY Fr.ON INCLUDING COVERED AREAS BVGH AS PATIOS,DRIVEWAYS,AND WALKS, THE p£RTY OR ADJOINING PROIgRTY. 777V .. . ld ... :.. .... ... FOR DEPARTMENT USE ONLY APPUCA►ION ACCEPTED BY DATE: Y v BEA:. TANK,FIT OR SUMP IMSPECTION By I / GATE_ ( 1 FINAL INSPECTION BV DATE G__ ,r P6 AObtTIONAL COMMENTS: 1 3r C II I ACCOUNTING ONLY: AID# FACE i I b PE CODE FEE INFO AMOUNT REMITTED HECK I W RECEIVED RY DATE it OR I PERMIT NUNRM a INVOICE a.5� l0 010 03x57