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APPLICATION FOR LIQUID WASTE PERMIT 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��/ �� r ENVIRONMENTAL HEALTH DIVISION PacrPad // P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201.0388 Z r L4 —C)'Z' (208) 468-3420 NON•REFUNDARE PIERMIT EXPIRES I YEAR FROM DATE ISSU D IComplots in TripUcata} APPLICATION IS HEREBY MADE TO THE SAN JOAOUIN 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 9.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESMR(APP.N�I ,�T D . ry q 2 CITY —[ v/� LOT SIZE �y OWNER'S NAME_b Z-�jg y�JU� ADDRESS.C.l 7 7 1/N�$elCL. '�L� ev 5=!GL �PHONE_�� CONTRACTOR ADDRESS Gfl l / �S 2.LLD �f� LIC# PHONE SUBCONTRACTOR_ j�JJ�G{� _L moi.-I..JG, ADDRESS57 Lc#A51-7-L-p0 PHONEE7Z?_'�.� 5 TYPE OF SEPTIC WORK: NEW INSTALLATION D REpAIRJADOITEON ❑ DE&TRUCTION 13 ENO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 15 AVAILABLE WITHIN 200 FEET OF BUILDINGA PERC TESTI.1 DHO W MANY` APPSepllon._. INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER 0 NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEvni OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPT SEPTIC TANKIOREA&E TRAP ❑TYPE/MFG CAPACITY NO,COMPARTMENTS PKG TREATMENT PLANT 11 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI J,EACHNO LINE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED 11WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 6EEPA4k PITS ❑DEPrH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE &LIMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY UNE 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 OWNEROR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT INTHEPERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHAT L NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUS-CONT KA(-.1 ING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO _NSATION LAW IFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE; S+�//l 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. :1. DUA[N=',IUIJCU 00 FI METS AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLODING CO VEMAJ AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. .i. . ..............' rs T�Iib: - ......Go ....... ..9F �!! ... .... .._ �xclSrirAa J. .... FT /yI .. -Er�rsrir+ 1 �'�• / ar3t..S J !SKS /a!,'f //J.SDy 1996 a .... P 1BL;IC HEALITI LIry ; '' ✓ Q i PJVIR VA1Eid1,4L I�ERL r; . .. ;..1D.21tl ............. . FOR DEPARTMENT-USE APPLICATION ACCEPTED BY DATE: AREA r gyp. TANK,PIT OR SUMP INSPECTION BY DATES FINAL INSPECTION BY / DATE_/o I ADDITIONAL COMMENTS: r 6�..�.I,-eo( 44 pCCOLINTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED 6=C41CASH RECEIVED BY PATEO 60/PERMIT NUMBER INVOICE# gd v 3 03a 5