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G . APPLICATION FOR LIQUID WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES 1 ( I �UF1" ENVIRONMENTAL HEALTH DIVISION P.O. BOX 389, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201.0388 (209) 468-3420 NON•REFUNDABI.E PERMIT EXPIRES t YEAR FROM DATE ISSUED O p� ICampkta in TripliutBJ APPLICATION IS HEREBY MADE O THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN' JOAOUIN COUNTY DEVELOPMENT!TITLE,CHAPTER 9-1110/.3 AND THE STAND �ARDS OF SAN JO AQUIN COUNTY PUBLIC HEALTH SERVICES. /ENVIRONMENT L HEALTH DIVISION. JOB ADDRESSIOR APNN__��{Cic �- eoY ll --CITY__.i T`�--,�C C _ - ��/� p� ,� LOT SIZE (� / OWNER'S NAME J- ADDRESS1.• Cj _ pHON t CONTRACTOR ADORE55_�N�'C . . 11CX C l� PHONE (M (1 I 1 SUR CONTRACTOR ADDRESS LIC# PHONE TYPE Of SEPTIC WORK:) E NEW INSTALLATION _ REPAIMADDITLON ❑ DESTRUCTION ❑ •• •� [ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 15 AVAILABLE WITHIN 200 FEET OF BUILDING.) PEAC TESTI4 1 1 HOW MANY IF INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL OTHER NUMBER OF LIVING UNITS:_N]CUMBER Of BEDRO MS: N NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3-FEET: ,.LTISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP ❑TYPE/MFG V CAPACITY NO,COMPARTMENTS vy PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION yROPERTY LINE "r.[�- LIFT STATION❑ SIZE IV�.. TYPE Of PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) p// J LEACHING UNE ❑ NO.&LENG H LINES DISTANCE TO NEAREST:WELL FOUNDATION�co PROPERTY LINE_ V FILTER BED ❑WIDTH N 'LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ' SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST.WELLFOUNDATION PROPERTY LINE r w DISPOSAL PONDS ❑MOTH 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 OFT HE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;"I CERTIFY THAT IN THE PERFORMANCE OFTHEWORK FORWHICH 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 SUB-CONTRACTING SIGNATURE CERTIFI HE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S C AIIgN LAWS OF ALI IA.' THE AP 'MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: DATE: 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. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY PT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. �:..........;.�..�. � .. ..... .. .'��. �� 'ter.:.. ' 1(. - wt� t : I ..........:: _ .. _ .... .. .... �iV _ r 51 FOR DEPARTMENT USE ONLY A 7fON ACCEPTED BY DATE: 1 AREA: 2J q Y R SU P I N Y �J DAT ! FINALL I I BY �`�' DATE ALSDITIONAL COMMENT : C� ACCOUNTING ON Y: AID# FAC# f PECODE AMOUNT REMITTED _ HEC ICASH RECEIVED BY DATE SR 1 PERMIT NUMBER INVOICE#