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APPLICATI014 FOR LIQUID WASTE PERMIT � " "--^--•.�.. ...� SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES �... ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN $T., STOCKTON, CA 96201.0388 {209) 488.1420 NON"REFUNOABLE PERMIT EXPIRES i YEAR FROM OAT- CiSSUEO APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONISTRUCT I AND Rs in 'IINNSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110.3 AND THE STANDARDS OF SN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESWOR APN,f � GITY ��/ '' OWNER'S NAME - �-� - LOT BiZE�',/� ��':y, ADDREes_. ��tll�� a✓ �_ - PHN7'RgCTOR 'ADDRESS ONE SU -_ /{J I D_ l / `UCS PHONE �r!�' i� _ I SUB CONTRACTOR ADDRESS [ —�L Lam# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADOITION ❑ DESTRUCTION❑ ti£ RANO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) ''',,,/// FERC TESTI.) j HOW MANY_" INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER❑ APPI[oe mon# NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF J FEET;- PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASE TRAP ❑TYPFIMFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST; WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEAC14NO LINE ❑ NO,A LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 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 0 DEPTH 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:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SN 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:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH 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 SUS-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 WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24}TOURS IN ADVANCE FOR ALL REGLARED INSPECTIONS. COMPLETE DRAWING BELOW. (� SIGNED% _ _---- TITLE:�� Lf'1!'� )_DATE: � PLOT PLAN[DRAW TO SCALES 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. 3 DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, _ INCLUDING COVERED AREAS SUCH AS PATIOS OMVEWAYS,AND WALKS. ONE HUNDRED FIFTY FT.ON S. LOCATION OF WELLS HIN US OF ........_. ....... .. ...., ....._. THE PROPERTY OR ADJO INING NTNG PROIPERTy.O ..,..,_ -,.,.,. L. .. ..... i _ : .. - .. ._ ... .. - ;...... - i ...... _ .i.... . ._..i...... ....... r _ : _ OF'h-FPARTMEIYT=USE'ONLY- it--1-7 APPLICATION ACCEPTED BY_t� Z - yB AREA: TANK,PIT OR SUMP INSPECTION.1 c 7: DATE ! 1 FINAL INSPECTION SY Ctl�- DATE ADDITIONAL COMMENTS: "+�l �� - F ACCOUNTING ONLY: Alba FAC# , PE CODE EE INFO AM UHT REMITTED CHECKSICASH RECEIVED BY DATE SR!PERMIT NUMBER INVOICE# lEc� o o S s �.3r�f