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APPLICATION FOR LIQUID WASTE PERMIT ..r i .. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ll ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-0380 (209) 488.3420 f'} NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 lCompletr in Triplicate) 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 COMPLIANC�W JOAQUIN COUNTY OB ADDRESS/Oft APNI LOPMENT TITLE,CHAP�4 �7 3,�_ER 9 3�AND y�THE STANDARDS OF/SAN�JOAQUIN COUNT)'PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH 61VI�IQN�LL-/,r��J -�y �� 61 A�EV I A/T�� _ CITY LV�� 1 ULOT SIZE UAc OWNER'S NAME j�� / L P ADDRESS �� it IV PH Nf CONTRACTOR L/V& cw7J Ajq _ ADDRESS P-05r,,I( 3714 UCy PHONE f .- O SUB CONTRACTOR ADDRESS L1CN PHONE TYPE OF SEPTIC WORK: ; .NEW..INSTAL ON ❑ REPAIRIADDITION ❑ DEG"LICTION ❑ IND SEPTIC SYSTI'•17TTER TTEO 4F.,PU6>`4C SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIO I I NOW MANY ` ` AppNaetlon 0 INSTALLATION E: 'RESIDENCE❑ COMMERCIAL ❑ OTHER❑ NUMBER OF LING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER FABLE DEPTH SEPTIC TANKIOREASE TRAP ❑TYKIMFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHINO LINE ❑ NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER Sm ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTHD16TANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAOE PITS ❑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 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 WORK FOR WHICH THIS PERMIT IS ISSUED,1 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CZ jATION LAWS P UFOANIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR/ALLL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW.7SIGNED X /L 1 TITLE: L/V✓w� DATE: ? Tl T PLAN IDRAW TO SCALEI 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, b. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDINGf COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 1 t},�L IC I�SIyuiW i !" rriy \J� eAm P ,L L IS rb LL=L FOR bEPARTMEIVT UbE ONLY ��J} r] APPLICATION ACCEPTEO BY VjJA-/ DATE: `� , D l AREA.'-2/ TANK.PIT OR SUMP INSPECTION BY DATE ! 7 FINAL INSPECTION BY L DATE �1 ADDITIONAL COMMENTS: rr ACCOUNTING ONLY: AIDR FACY PE CODE FEE INFO AMOUNT REMITTEDCHE /!CASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE 0 j, $a. 1'7� 111/0