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,%' APPLICATION FOR LIQUID WASTE PERMIT ..� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �01 P.O. BOX 368, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 (209) 460.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED 0 ICampblta in Tripii"W APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDlOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANC�WffIJ10 JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVI$y¢N "4 JOB ADDRESSIOR APN/ �f �cr 7�' � 14A rG v ��v T - _—CIT-Y� f ��} I C�11r/LOT SITE�c OWNER'S NAME 7 L ADDRESS y� Z3 - C!V A NiE �7 7 CONTRACTOR D � � ADDRESS 1 y` 1JC•JX �� TU�. r__LICN PHONE �1E� "I4 V__7 SUB CONTRACTOR ADDRESS LIC* PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITtON ❑ DESTRUCTION ❑ ;NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FELT OF BUILDING.} PERC TEST(*][ I HOW MANY AppIloedon* INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER ❑ NUMBER OF LIMNO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKJOREASE TRAP ❑TYPFIMFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE_TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM( LEA94NO UNE ❑ NO.&LENGTH OF UNES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BEP ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 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:"E 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 CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S]TON LAWS F LIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALLL REQUIREED(INSPECTION& COMPLETE DRAWING BELOW.SIGNED XL TITLE: CI L�� ` DATE: 4 f T 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. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS YoTHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY, Pea& —_ �E� J�1lGprZhnlr W;�1 r25 ``l FOR DEPARTMENT IIF ONLY APPLICATION ACCEPTED BY �C,` G DATE: y - l A9EA:,9-I,2 _..— TANK.PIT OR SUMP INSPECTIONAW DATE ! ! FINAL INSPECTION BY ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC* PE CODE FEE INFO AMOUNT REMITTED GNE *!CASH RECEIVED BY DAV SR I PERMIT NUMBER INVOICE IF �t� Sal 2 2-1 0