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-I.ICATION FOR LIQUID WASTE PERMIT SA9*&wnaUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION x" r " P.O. BOX 388, 445 N. SAN JOAO.UIN ST., STOCKTON, CA 95201-0388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRDM DATE ISSUED `r �� (Complete in Triplicate) OUu I 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 9-1 110.J31 ANND.T+HE S,T/ANDARDS`OF SAN JOAQUIN COUNTY PUBLIC HEALTH`SERVICFS,ENVIRONMENTAL HEALTH DIVISION. J JOB ADDHESS/09 APPNNI 14 23 i' tnr r��`Mr /4A IVY i7—V /AN� 3�j ! y� y��, CITY ,7L'��)I ��] �-f�`r LOT SIZE ! j . DWNEWS NAME_!y'ZQy/',n'LLr {JSP A!'•1 Ot D ADDRESS_£'Z3 Y/ C- i-�A RN E� L-A Nr _ PHONE DONTRACTOR I�OJY 4•►"r S/V ADDRESS 156- ( RLOL LIC- PHONE 41 SUB CONTRACTOR ADDRESS �;V-,jLIC- PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIAODITION ❑ DESTRUCTION ❑ ` {NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIaI f IH/OW MANY APdiastion- ,1!✓ r�S INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF IMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING LINE ❑ NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS ❑ 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 DISTANCETO NEAREST:WELL FOUNDATION PROPERTY UNE 1 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,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOHKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SI ��1NATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOPKMAN'S COMP TION LAWS ORNIA.` THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED IIINSPECTIONS, COMPLETE DRAWING BELOW. 1 . LrC.- U I�i.�JV•�il` DATE: ! SIGNED% TITLE: ___ -./,LIN(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 W. 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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. Vv I TrI . . .. . . . . . . t- I49A . . .. . . . . . . . . . � wopwaft PHRCe=1 2 Cly-nil P yM I 77=7 . _ v _ . . . . . . .. KrI FOR DEPARTMENT USE ONLY to APPLICATION ACCEPTED BY DATE: (TI716 AREA: TANK,PIT OR SUMP INSPECTION BY / DATE ! ! FINAL INSPECTION BY ~' �KTE ! �! ADDITIONAL COMMENTS: r L z:61 r� -7 ACCOUNTING ONLY: AWN FAC- T PE CODE FEE INFO AMOUNT REMITTED CHECK ASH RECEIVED BY DATE SR!PERMIT NUMBER INVOICE 0