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f 00003 '',PLICATION FOR LIQUID WASTE PERMIT Smv JOAQUIN COUNTY PUBLIC HEALTH SERVICES' ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0389 (209) 468.3420 FILE Copy NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompiets 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 COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR AP/INA` C 1 9 l� l a vtc_. .. -••. _ Cmr��, gtLOT �yS.UE 0� �G OWNER'S NAME LO L` �'�'LM( ✓l ADDRESS PHONE/ CONTRACTOR b ADDRESS 1� Y ��'t= K-�Fo•-+ �1�[ LIC* PHONE •3(O .S SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ MO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(,.)[ I HOW MANY Application# INSTALLATION WILL SERVE: RESIDENCE 13 COMMERCIAL ❑ OTHER❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: U NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: �l �1FPIT/BUMP SOIL CHARACTER: I 5n'e_t 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(ENCLOSED SYSTEM) LEACHING LINE ,® NO.&LENGTH OF LINES—12 X _J DISTANCE TO NEAREST:WELL ISS FOUNDATION-'S t PROPERTY LINE IC7� FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEVAOE PITS Ea DEPTH -91S- SIZE NUMBER_,,, DISTANCE TO NEAREST:WELLi' FOUNDATION S p! PROPERTY UNE—/00' SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION 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 JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM SATION 7FJFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: Kd G. "1 C^ DATE: PLOT PLAN IDRAW 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 INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ..... ...... .... .,......,. .._, ., -. _ - ., .. .... --- - - ..,.... - .: 4�J 1 ... ... ......... ...__ .,..,.,. . .. - .. ., .. .. .. _ ..,. .. v ..,.. .......... . ...... ................... ................ ........,. :. ...................E ... ....,.-.... i.... -- ......... .. ... ........ _ I _ � , L:. .......... NT.................... ..... .. MA.R.2.1.199 _ ..... .... �1N CC.u.P�rr A ......... ... ,.. JIVCS.iON FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: Z AREA: aI " TANK,Pe OR SUMP INSPECTION BY DAT�(/69 �FINAL INSPECTION 8 DATE f ! �4/ � / ADDITIONAL COMMENTS: rr I ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED CHECK# ASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE 0 t o !1s 31x11 1l a �