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APPLICATION FOR LIQUID WASTE PERMIT pgYMENT Sr,.d JOAOUIN COUNTY PUBLIC HEALTH --AVICES RECENED ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 AUG 3 1 2009 (209) 468-3429 ~: ;u SAN JOAQUIN COON TY NON•REFUNDARLE PERMIT EXPIRES I YEAR FROM DATE ISSUEDQUBLIC HEA'TH SERVICES (Cwnplete In T*kete) Ef1VlFtOKMENTI+:.PiCALTK DIVISION APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.2 AND THE STANDARDS OF SAN JOAOUNN COUNTY PUBLIC HEALTH SERgV)•I�CEE@.EENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# //0j7(— Y) l�`� 1�h t ui. . 1 0 A 1 CITY �I 1�_L ^1 LOT SIZE r�n� tPHONE �.p, ADDRESS 2- OWNER'S NAME CONTRACTOR ADDRESS LIC#Q RDNE7 1"i SUB CONTRACTOR r ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRfADDITtON ❑ DESTRUCTION IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TE@T(e)I 1 HOW MANY Appev�tlon INSTALLATION WILL SERVE-- RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF ENPLOVELS: - CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITfSUMF SOIL CHARACTER' WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT 4TAT1ON❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR{ENCLOSED SYSTEMI , LEACHING UNE ❑ NO,&LENGTH OF LINES DISTANCE TO NEAREST-WELL FOUNDATION PROPERTY UNE i FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELLFOUNDATION PROPERTY UNE ' 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:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIOTH 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 OF THE SA14 JOAQUIN COUNTY.HOME OWNER OR LICENSED AdENT-8 SIGNATURE CERTIFIES THE FOLLOWING.-'I CEKFIFYTHAT IN'rHE PMVOWANCE OF THE WORK FORWHICH THIS PERMIT 10 ISSUED,1 SHAD.NOT EMPLOY ANY PERSON M @UCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB,CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TH38 PEIWITf to ISSUED.I 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 f SIGNED X / TITLE: C-- 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. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 5. LOCATRON OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOININO PROPERTY. I ..... .. .. ...... ... .,.... j ...-. !!! .. ..:. v e. ...... . . . : . .. ......... .......:.. :. . ...... .... .. ..... ... ... .. r. .... . ..... .. ....... ice `' . ;........ .................... ... .. ........... ..:... _ . ... ........ ... .::.. .. . . .;..... ., .. .. 3 . - - - .. .. .:. ...... I .., .. .. .-... :. ........ ..... .. .................... .. .. .. .. .. 4 ..... .. ...... . ....:... ..................... ................ ................. :......: .. . ... .....t�o � v........ C r'tOR tlEPARTMEN_ T US�QNLY APPLICATION DATE: AREA:ACCEPTED BY � �• TANK,PIT OR SUMP INSPECTION BY DATE f / _FINAL INSPEGTKON ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID/ FAC* PE CODE FEE INFO AMOUNT=1711) IECK+ ASH RECEIVED BY DATE SR T PganT NUMBER INVOICE+ �I 14.-Txt o-75 Pub.HeoBkh Serv.-Enviro.c 74(3/96) 9,73 "1 I V1 a L A A.1 � !