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,PPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ' ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 . (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES ! YEAR FROM DATE ISSUED (Complate in Triplimml 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. JOBADDRESSIORAPN# 23521 N. Mackville Rd. c,T„ Clements LOT SIZE 5acres C. Edward Jones Co. 900 E. Victor Rd- Lodi PH 334-2964 OWNER'S NAME ADDRESS ' CONTRACTOR Morton Septic 121 E. Churchill St. LIC#444225 PHONE ADDRESS i SUB CONTRACTOR {p1 ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.1 PEtC TESTIS}I I HOW MANY Appli-don I INSTALLATION WILL SERVE: RESIDENCE ( COMMERCIAL ❑ OTHER❑ NUMBER OF LMNO UNITS: NUMBER OF 13EDROOMS:� NUMBER OF EMPLOYEES: I CHARACTER OF SOIL TO A DEPTH OF 3 FEET:s a nd y PIT/SUMP SOIL CHARACTER: sand WATER TABLE DEPTH SEPTICTANK/GREASETRAP EXTYPEIMFGt-t)T!_C*_r@te/PS.L CAPACITY NO.COMPARTMENTS2 PKO TREATMENT PLANT 13DISTANCE TO NEAREST: WELL 10 0 I + FOUNDATION 20 I PROPERTY LINE 5 0 R + LIFT STATION❑ SIZE TYPE OF PUMP It SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE Q NO.&LENGTH OF LINES 3/401 1 l i n e s DISTANCE TO NEAREST:WELL/0 0+ ' FOUNDATION 7 5 I PROPERTY UNE 2 0 R FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION _ PROPERTY LINE SEEPAGE PITS 0� W{DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE A SUMPS 1u DTH�LENGTH 10 1 DEPTH 11 H DISTANCE TO NEAREST:WELL 10 0 1 '}FOUNDATION 7 5 ' PROPERTY LINE 20' ' 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 JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THEBAN JOAQUIN COUNTY.HOMEOWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'ICERTIFY THAT INTHE PERFORMANCE OFTHE WORK FORWHICH 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPE TION LAWS OFC RNIA." THE CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X-7797�� TITLE: Cnntrar-tor DATE: - PLOT PLAN(DRAW 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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON F INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS AND WALKS. L THE PROPERTY OR ADJOINING PROPERTY. J . ., .. f : ... .. f ,.... .............:.... . . .�// .. ... I .. ....j,..,.. .. ... ........ ..,..,. .. .. .. .. .. _ _ _ .. .. .. .. .. .... . ...........:.. ....... ......... ,...: ...: ....... . .. ..... . ... ..... .... ...... .... .. .. .. .. ... ... ..... . .. .. ............. . ...:. .. ... ... .. f-��US�G� : .. :..... . I .. .... .. . ..::..... ..... <... ......... ... .. ... :.... .....'. . - - A. FOR DEPARTMENT USE ONLY APPLICATION ACCC''EyyPTED BY DATE: i� S�AREA:�ry �7�Q' p TANK,PIT OR RIUMP INSPECTION BY DATE 'I FINAL INSPECTION BY TE 17® 1 /L� ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDS FAC# PE CODE FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE# Z � 2 3 Z 4 Sof oS '� '' •�_