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APPLICATION FOR LIQUID WASTE PERMIT ft-AN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 (209) 468.3420 f� NON•REFUMDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O � (Complete in Triplicate) APPLICATION IS HEREBY MA E TO T AN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CwAFTER 9-1110.31 AND THE STANDARDS OF SAN IOAOUIN COUNTY PUBLIC HEALTH SERVICES,F,N VIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNK /7//�i✓\ /!1//. Gc��,ti ` �1 '�'�S 1�- Y� —�G L / OWNER'S NAME 1 CITY m /' LOT SIZE r� /y ? ADDRESS 1 ' C I � C�1PHONE CONTRACTOR �'r l r / ADDRESS—,, / dG-/7 LICN PHONE L� 7/07/ SUB CONTRACTOR ADDRESS LICK PHONE TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEINER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW I I HOW�MANY � Applioetlon K��_/,� INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL 13OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPEIMFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHNG UNE ❑ NO.d LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS C1 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑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 JQAOUIPJ C UNTY.HOME OWNER OR N AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH JJJ THIS PERMIT IS ISSUED,I SHA N T Y ANY PERSON IN SUC A N ER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNAT E I THE FOLLOWING:.* C I T IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSAT N S ALIT NIA." E CA UST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS. COMPLETE DRAWING BELOW. a SIGNED X TITLE: �f G/� P� a C , Cf r`� DATE: J 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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON r INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. TEN F ATIVE MAP �Lf / OlvvERS p APONC26c,In 7-/o „�. = � PFo�Ecr cEsc4iPriav �+- Z / / r m�riw ii.'nwaa r.o a PARCEL Z a / NOTES: mor ar. Q -a v..ran..% sur�c / s»r.r vuw.sr: .vrnr ' e•�cnran �e.r r. icaea.w w.o i..rwv.- �.eer•' r m rl r Pt' f 7'T w < fSITE- R E CD-: IVB .�� �Ae:�r rE vwr za 0A 2 2 1994 SAN JOAQUIN COUNTY <'�'<r �•� PUBLIC HEALTH SERVICFS FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY C . _ DATE: Z AREA: TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BYDATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDK FACN PE CODE FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE N / L-L--) L