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r APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH [DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., S7UCKTON, CA 911201�0388 {209) 488.3420 NON'REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CGmplata in Triplicatsl APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMi r TO CONSTRUCT AND10R INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 8-1 1 1 O.3 AND THE STANDARDS OF SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS?OR A/},PNNNX 1//1 (f/d / _ f � +� Al / CITY N C. . ia� LOT SIZE OWNER'S NAME /\L�� f-7!�J�T� �I (� ry `ADDRESS- PHONE p�' CONTRACTOR �.� z ADDRFss��,:✓e,:d " �1.:'T./(^� v -� /e 1-o Ir{ LIC* p�LPHONE SUB CONTRACTOR' ADDRESS O aft � +� ✓ / j F^�/-' LIC*�� r'`y}PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION WO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER iS AVAILABLE WITHIN 200 FEET OF BUILDIN(3.) PERC TEST(.)I )HOW MANY—�-� Appflaevort i Ei INSTALLATION WILL SERVE: RESIDENCE* COMMERCIAL © OTHER 11_..M.. NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ' NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET:— ,L PITISUMP EMI!_CHARACTER:_ _ WATER!ABLE DEPTH SEPTIC TANKIOREASE TRAP ❑TYPEIMFG ^� LL°IY:►1r�i .."APACITY O TP-) `- NO.COMPARTMENTS AR PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL..-L .T� FOUNOATION 1 S'ROPERTY LINE LIFT STATION❑ SIZE TYPE OF P y+SAND OIL SEPARATOR(ENCLOSED SYSTEM) � ,y. LF.ACHNO LINE ❑ NO.&LENGTH OF LINESir-! DISTANCE TO NEAREST:WELL�FOUfdDATION �1�� —PEATY LINES--j FILTER BED ❑WIDTH LENGTH__DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEFTFH DIST Ar 177 TO NEAREST:WELL FOUNDATION PROPERTY LINE_ _ SEEPAGE PIT$ 11 DEPTH r L� JI r•iUMBEP. )iSTAN'CE.TO NEAREST:WELL1 F0UNDATIONF11OPE.RTY LINE__ .. SUMPS ❑WIDTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE r'•'_ DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I 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 SAID JOAQUIN COUNTY.HOME OWNER OR LICENSE;?AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 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 C. SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. "I CERT f"THAI IN THE PERFORKIANGE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOtMRED INSPECTIONS. COMPLETE DRAWING BELOW. Ve— •' .. • fLl �'^ti,4�.,J � .. r "�.�c SIGNED X e TITLE: DATE: �� ,��_ (C\l 8 PLOT PLAN[DRAW TO SCALE)SCALE "to 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: S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FE,Of- INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOININ PROPERTY. 1 � a� -7 FOR DEPARTMENT USE ONLY " APPLICATION ACCEPTED BY "'� - .... DATE: L AREA: �-».... �.. �q�''y i.. 1 x'4'7 TANK,PIT OR SUMP INSPECTION BY W. 1- a' 61A O I 1 FINAL INSPECTION BY DATE 1 ! ADDITIONAL COMMENTS: SIGNED 1 ACCOUNTING ONLY: AID* FAC* PE CODE FEE INFO AMOUNT REMITTED CHECK*f ASH RECEIVED BY I DATE SR 1 PERMIT NUMBER INVOICE I