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APPLICATION FOR LIQUID WASTE PERMIT ,,ddN'JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P-O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 489-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11n10.3�AND jTHE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,E VIRQNMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# /,54 W,C! CEJ SLC/y CIT�Y-- � LOT SIZE OWNER'S NAM% ADDRESS �J W C�-T/—�YIi/ CSL. PHONE _MU 1jI6, �^ �7 22/ q ,�-�--. 61 I FLEE C-ADDRESS_ Z79 DO&I G2.K >~A,� C- UC#5'2q 'Z8 PHONE3L9- /581 L-U^ ��M ///,,,JJJ i CONTRACTOI�W!2 G I +QUI MA �k I� ADDRESS�B e4J J E i•t! C � LICA' 'd�o� PHONE (45— C TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI*►I 1 HOW MANY APdlastlon I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL 13OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKICREASE TRAP ❑TYPEIMFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.i LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPT# 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 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 SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE LLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIO OF CALIF RIA.' THE APPLICANT MUST CALL M HOURS IN ADVANCE FOR ALL REQUIRED INSPEECT,I,ON& COMPLkTE DRAWING BELOW. I SIGNED XZ TITLE: y DATE: !Z PLOT N(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROA S 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. TLS= �A4btTorLL�C� ' k�/ c. slkl f, MScVs i9lll ► �V U t u'T .. .. F--�To fj tT'E S&Lon L- Sc_[Lr r 7 cvS�rvl� 3 `I�ii�� a . �kq 5= 37 MW ) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: I I V' 1.� AREA: / I It=11 TANK,PIT OR SUMP INSPECTION BY //1 t ATE / / L✓ FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID) FAC# PE CODE FEE INFO AMOUNT REMITTED CHECK#/CASH RErEIVED BY DATE SR/PERMIT NUMBER INVOICE Jr