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AF�ATiON FOR LIQUID WASTE PERMIT •}� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES +� ENVIRONMENTAL HEALTH DIVISION P.O. !1O]( 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201.0398 (209) 468.3420 copy NON-REFUNDABLE PERMIT EXPIRES I 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 WOR(DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN OAOUIN COUNTY PUBLIC HEALTH SERV ,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APNr �— CITY LOT SIZE JWNER'S NAM[ AODRES �• �7 • �93 PHONE :GNTRACTOR �� ADDRESS LIC/ PHONE 'UB CONTRACTOR ADDRESS _ LIC) PHONE .� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RE'PAIRIADDITION ❑ DESTRUCTION ❑ NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 100 FEET OF BUILDING.) PERE TESTI*]I I HOW MANY - _ Appioadon• NFTALI-ATION WILL SERVE: RESIDENCE COMMERCIAL OTHER❑ iUMBER OF UVRNG UNITS: NUMBER OF RWAOO S- NUMBER OF EMPLOYEES: :HARACTER OF SOIL TO A DEPTH OF 3 FEET. 51!W4" PITISUMP SOIL CHARACTER: WATER TABLE DEPTH ;EPTIC TANKIOREAAE TRAP XTVPEJMFG CAPACITY 40'vy�} NO.COMPARTMENTS .T Q•� NCO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATI N PROPERTY UNE Q i UFT STATION❑ SIZE 'TYPE OF PUMP...�r�L SAND OR SEPARATOR(ENCLOSED SYSTEM) s�7 EACHINO UNE D NO.&LENGTH OF LINES IVV DISTANCE TO NEAREST:WELL Zee FOUNDATIONPFWPERTY LINE �" ! ILTER BED WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE _ ROUNDED ❑WIDTI# L-NGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FFPAGk Pi'fm i7I I.f.Cq I I _ nQ1, NUMBER - DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE LIMPS ❑WIDTH_ LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE IISPOSAL PONDS ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE `..J HEHERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ND FIEGULA'fTONS OF TI I[SAN JO AOUIN COUNTY.HOME OWNER OR LIC ENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFYTHAT INTHE PERFORMANCE OF THE WORK FOR WHICH HIS 11 HM-T IS INNU EO,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 08-CDPI FRACT INC,;If;NAT)IRC CERT IFIFS THE EOL OWIN •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO JOPXN1AN"' C0Ld1'PII;AT hN I AWr OF CALIFORNIA.' E APPUC ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. IGNED X_w.;Z TITLE: DATE: —5 � PLOT PLAN[DRAW TO SCALE)SCALE 'to NAMES 04=;TM'F1 S OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLih'E C1f`-'LRE FNJOI%t:HTY,WITH DRMENSION6 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. •\ 11i,v.f.tatq'di:U!',LIT[1NFS 6.iJD i_OCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON iNCIODING COVEFtFp AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, THE PROPERTY OR ADJOINING PROPERTY. fy/n o . 7c3 . y, .... 4S� - .....,..... - COP- .:.. ' ..... � o . . ... ... . :. PAYMENT... � IN fUm r „. .... _ CNV) �(-�(C?�tC� Lr•i �t�NIT�-�= .: . ... .. `�5 r -I:l: F ..... ..:... <... ;.. �{VI�i4iiES�l lt','�i7Ef 5i'.rfivil'!ci ,I', .