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'tPPLICATION FOR LIQUID WASTE PERMIT SAR'., JAQUIN COUNTY PUBLIC HEALTH SE..--CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1CempletB in Tripli"lls) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/011 APNI C E CLOT SIZE OWNER'S NAME rr (JADDRESS PHONE �+ �• L/ADORE55 �'O 4 i �/ .�,,C �✓ G / LICR PHONE_ CONTRACTOR C� ! SUBCONTRACTOR ' ` ADDRESS LICE PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.) PMC TEATIO 1 1 HOW MANY Appilmdon INSTALLATION WILL SERVE: RESIDENCE MI COMMERCIAL ❑ OTHER ❑ NUMBER OF WING UNITS: NUMBER OF BEDROOMS: NUMBER Of EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITl6UMP SOIL CHARACTER- WATER TABLE DEPTH SEPTIC TANKIGRE"I TRAP ❑rI FwFO CAPACrTY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING 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:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PRDPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE To NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WTTH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REOULATMNS OF THE SAN JOAQUIN COUNTY,HOME OWNER ORUCENSED AOENT'e SIGNATURE CERTIFIES THE FOLLOWING:'I CERrIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 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 COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGISRED INSPECTIONS. COMPLETE DRAWING BELOW. TITLE: Cjr . DATE: SIGNED X PLOT PLAN IDRAW TO SCALE)SCALE--- I. CALE^ '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, 6. LOCATION OF WELLS WITHIN RADrVS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYB,AND WALKS. {- THE PROPERTY OR ADJOINING PROPERTY. .......... - _ l� .. .. ., _...... . ;. l.1.. . ..... ' :.......:......:.......:......:.......:.......:......:......:......:......:..............:............. . .. ........... ..:......:.. ............ ...:.. ..:......:.... _..:.....:..............:.. .. .. . .. ................... a-tr�IrC 1 ..; _.. ... :.. "rNVIR�11�f116Fi A�F" ... q d TOR I'+Ev ENT USE ONLY ^"�f] r'7 APPLICATION ACCEPTED BY W� DATE- ` r`RE'°' "7R%JL TANK,PIT OR SUMP INSPECTION BY DATE 7 ! FINAL INSPECTION BY DATE \ IZ, AOUITIONAL COMMENTS: ACCOVNTING ONLY; AIDE FACE PEC�O.D-`1E_ FEE INTO AMOUNT RENT ITER CIIECKM CASH RECEIVED BY DATE SR!PERMIT NUMBERR INVOICE f 2 ✓ SCJ ^` I UO/ Pub.Health$erv.-Enviro.174(3196)