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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA SMI-388 (200) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER iCompi.to in Ttipiiaah) APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED, THIS APPLICATION IS MADE IN COMPIJANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JO� COUwrY P SLICTSLTH SERVICES, ,EENVIRONMENTAL HEALTH DIVISION. JOS ADDRES610p APN>! !✓ ^'1137 L�%��J ZZ -�.+--/t�/��1] LOT SIZ�� OWNER'S NAME AODREBS [ E f 6CJ' �/ PHONE �1�. CONTRACTOR ADDRESS LIC# RHONE SUB CONTRACTOR ADDRESS UC• PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADdTION ❑ DESTRUCTION ❑ IMO SEPTIC SYSTEM PERMITTED IF PUBLIC SEINER IS AVAILABLE WITHIN 200 FEET OF SUILDING.I PLIC TESTI+1[ 1 HOW MANY �r Applloo0on P INSTALLAT30NI WILL SERVE: RESIDENCE SLY COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS:- NUMBER OF BEDROOMS: Z-- NUMBER OF EMPLOYEES; CHARACTER OF SOIL TO A DEPTH OF 3 FEET; PITUBUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKMRFASE TRAP ❑TYPE/MFO CAPACITY 1'1'1 �^NO.COMPARTMENTS L PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE IW LIFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE 0' NO.i LENGTH OF LINES I DISTANCE TO NEAREST:WELL-Lao FOUNDATION S� PROPERTY LINE ` FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED rl 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE 17TS )jA- ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE I 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 BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'ICERTIFYTHATINTHE PERFORMANCE OFTHE WOW FORWHICH THIS PERMIT IS ISSUED.I 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT to ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPVCTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: DATE; PLOT PLAN(DRAW TO SCALE)SCALE to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, i. 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, 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. .. .......... . . r ..: .R:vw.4-1-- . .. PA��t1; EN ) . 1 RECEIVE - ..:AN JOAQUlra cd.UNT.y