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PPLICATION FOR LIQUID WASTE PERMIT SA`I 'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION` P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.0388 (209) 468.3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �^�! h� `(J—3U� r [Complete in Triplintel GLY ` APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN 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 ADDRESSIOR APNN -4 230 r �y RN �, CITY_L-U b _ �.t � LOT SIZE {�� OWNER'S NAME �] ' �� - c .OA D ADDRESS 7-y A RN E N •• PHONE CONTRACTOR—Dig ADDRESS Y-D130)c I ( SUB CONTRACTOR } ti v ADDRESS "i 53et i LIC# PHONE TYPE OF SEPTIC WOR NEW INSTALLATION ❑ REPAIR/ADOITION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(t)1 I HOW MANY AOPMoetlon s A1,9 M S � INSTALLATION WILL SERVE: RESIDENCE 1:1COMMERCIAL 1:1OTHER 11 NUMBER OF IJVINO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES; CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP Q TYPE/MFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT© DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE Of PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BW ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONOS ❑WIDTH 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 SAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT 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 CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SI ATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM TION LAWS RNIA," THE APPLICANT MUST CALL 24 HOURI IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X 'Chi TITLE: DATE: O - PLD PLAN[DRAW TO SCALE)SCALE "to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUN ING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH O(RECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr.ON •� INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. k Tri A QIA 41 . . . . . PAI¢tF-t irtfORtZEt � z I" P PARC-I- 3 O _ PflRCFi . . . . . . . . . FOR DEPARTMENT USE ONLY 7 +��I(0�L APPLICATION ACCEPTED BY DATE: I AREA; L f TANK,PIT OR SUMP INSPECTION BY / DATE / I FINAL INSPECTION BY y� E ! C! ADDITIONAL COMMENTS: f d 7"- 7 ACCOUNTING ONLY: AID# FACT PE CODE FEE INFO AMOUNT REMITTED GHECK ASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE I