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F;L APPLICATION FOR LIQUID WASTE PERMIT SAH'JOAQUIN COUNTY PUBLIC HEALTH SERVICES P.O. NMENTAL BOX 388, SION 304 FASTOWEBER AVENUES ITOCKTON, CA 95201388 SCANNED (209) 408.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /� (Complete in Triplicate) v APPLICATION 16 HERESY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THISC2gPADEIVNMPLIANCEMATH 0 JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. SAN JOB ADDRESSIOR APN# 1 CITYLOT SIZE_&a!t_ OWNER'S NAME��_C`( 4� ADDRESS - PHONE CONTRACTOR .9:�.� .� r ,� , ' a '" ADDRESS ff3tlej '.t} - LICE PHONE SUBCONTRACTOR ADDRESS UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION 6. DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERS TfBTNI[ 1 HOW MANY INSTALLATION WILL SERVE: RESIDENCE B COMMERCIAL ❑ OTHER El ApDllaetlon i NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: C, PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPvmrG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑1I--SIZE TYPE OF PUMP SAND OIL SEPARATOR JENCLOSEU SYSTEM) LEACHING LINE LXt�NO,a,R LENGTH OF LINES -f� DISTANCE TO NEAREST:WELL FOUNDATION '— J_D0' PROPERTYUNE_.�� FILTER BED ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE MOUNDED C3WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELLFOUNDATION PROPERTY LINE �- SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS 11 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOCAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE p/y` I HEREBY CERTIFY THAT 1 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 OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WOW 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 SUB-CONTRACTING 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 COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. i I SIGNED% TITLE:_ GATE: PLOT PLAN[DRAW TO BCALEI SCALE to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, �rW�Q 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ` 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCT E8, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, INCLUDING COVERED AREAE SUCH AS PATIOS,➢RIVEWAYB,ANp WALKS, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON h THE PROPERTY OR ADJOINING PROPERTY, 1 .. c k . Naf IV t, „ _..k,�.... .. �f _. r.�F , . ..... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: TANK,PIT OR SUMP INSPECTION 8Y DATE r r FINAL INSPECTION BY DATE I ADDITIONAL COMMENTS: v7n ACCOUNTING ONLY: AID# PACO PE CODE FEE INFO AMOUNT REMITTED CHECK/ ASH RECEIVED BY DATE IT NUMBgt INVOICE Ir - q shoo n�3 C Doi