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APPLICATION FOR LIOUID WASTE PERMIT
<br /> *AN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> P.O. BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201.0388
<br /> (209) 468.3420
<br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> (Complsts in Tripkats)
<br /> 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
<br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE 8.TANDARDSO,•F SAN
<br /> JOAQUIN COUNTY PgjBUC ALTrH S VIC,rES/,ENVIRONMENTAL
<br /> NVIRONMENTAL HEALTH DIVISION.
<br /> JOB ADDRESSIOR APNN �Q � /CRY
<br /> LOT SIZE
<br /> OWNER'S NAME `J/J>E!.f �.!' .. ADDRESS t �• f�/f. p��D ArG
<br /> /E PHONE
<br /> CONTRACTOR � .3C,�d i I��j$ - ADDRESS G d (.,,a ,�.�e�y,+ LIC#4 PHONE {
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<br /> SUB CONTRACTOR ADDRESS UC#
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<br /> TYPE OF SEPTIC WORK: NEW INBTALLATLON ❑ REPAIRJADDITION ❑ DESTRUCTION ❑ J
<br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(s)i 1 NOW MANY /
<br /> APW)tRlaon#/. �q
<br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ 1�
<br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:
<br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH - -
<br /> SEPTIC TANKIGREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS
<br /> PKG TREATMENT PLANT El DISTANCE TO NEAREST: WELL
<br /> FOUNDATION PROPERTY LINE �y
<br /> LIFT STATION Cl SIZE TYPE OF PUMP SAND OIL SEPARATOR[ENCLOSED SYSTEM) PAYN', NT
<br /> LEACHING UNE 13 NO.m LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION F R t rIlyfia—`
<br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION �Ty LINFI +
<br /> MOUNDED 13 WIDTH LENGTH DEPTH . DISTANCE TO NEAREST:WELL FOUNDATION UNE
<br /> SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION
<br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATIONrt Is
<br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH ENYWO,
<br /> DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE r I'
<br /> 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
<br /> 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
<br /> 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
<br /> 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
<br /> WORKMAN'S COMP SATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW.
<br /> SIGNED X yP TITLE: :�/�/?�']1>2lf% DATE:
<br /> PLOT PLAN(DRAW TO SCALE)SCALE "to i
<br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. I
<br /> 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED
<br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.
<br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON
<br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY.
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<br /> 34,44*M3R3
<br /> NET
<br /> FOR DEPARTMENT USE ONLY
<br /> APPLICATION ACCEPTED BY DATE: :ITE
<br /> TANK,PIT OR SUMP INSPECTION BY DATE ! ! FINAL INSPECTION BYIff
<br /> ADDITIONAL COMMENTS:
<br /> ACCOUNTING ONLY; AiDB FACII
<br /> PE CODE FEEINFO AMOUNT REMITTED HEC lCASl1 RECEIVED BY DATE SR I PERMIT NUMBER INVOICE/ -
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