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APPLICATION FOR LIQUID WASTE PERMIT p SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 2 ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON,CA 96201.0388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Csmpists i6 Triplissts) 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 9-111110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# I& p C J J/ ,4 laS� CITY �5&.jo � e#koo' LOT SIZE OWNER'S NAME /J F. /7. .�.�Yd ((( LLG' PHONE CONTRACTOR l�L.t,��'VE�_ ADDRESS LIC# ` PHONE SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIQ[ 1 HOW MANY Appiiostion# INSTALLATION WILL SERVE: R[SIDENCE COMMERCIAL 13 OTHER 13NUMBER OF LIVING UNITS:—t//—'_ NUMBER OF BEDROOMS: •� NUMBER OF EMPLOYEES: CHARACTER IG SOIL A DEPTH OF 3 FEET: DUnM/P S L CHARACTER: WATER TABLE DEPTH -- SEPTIC TANK/fYiEAbE TRAP 'lkxy TVPEIMFG L ��l CAPACITY / NO.COMPARTMENTS PKG TREATMENT PLANT 11 DISTANCE TO NEAREST: WELL FOUNDATION I PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE 13NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERJ�R�AN@/ T FILTER BED 13WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PRO PE"0 r-'°9,f r,1-f MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPnSRRR(TTTIYYY�II IN �..-,�M Fq I_ SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROR[IVYILIN� Vju SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATIONPERTY LINE ` r` ry DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PRO P BL HEAL7T77E7�TI—CE„ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ��.5'j Iv N AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOMEOWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 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:"I CERTIFY THAT IN THE PERFORMANCE 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 REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. i SIGNED X /..--' TITLE: �G /,moi.. DATE: /OZ 9'/b` 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 FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 4 4--.� 33 44. I t _ '��av -7[DvD FOR DEPARTMENT USE ONLY pp�� j APPLICATION ACCEPTED BY , w , DATE: V ,71 q' AREA: TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE C' e ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED CK#/CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE# f LS D 355/