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s7 APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 962010388 (209) 4683420 NON-REFUNDADIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplieete) APPLICATION 19 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 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APJY1� ( ��p//SIC fJ G LfTY/fG G'/O/ LOT SIZE OWNER'S NAME c��i-r'y�/ �(//j111111 f_/C__ADDRESS / )� PHONE , ✓ CONTRACTOR .f�aL/GLrr IO-�A ADDRE6fi ��Ld�!>'R�//C.1�7.R^ IICi� PHONE SUBCONTRACTOR ADDRESS -UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEIRC TESTW 11{-HOW MANY INSTALLATION WILL SERVE RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NLMYFA OF LIVING UNITS:_ NUMSM OF SEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH S SEPTIC TANK1011FALE TRAP ❑TVPF/AIFG CAPACITY NO.COMPARTMENTS PRO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT 11TATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.S LENGTH OF UNE 6 DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DERN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE c SEEPAGE FITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE ,S!_ SUMP{ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTARCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 1' I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW(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 INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A6 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM NSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED% �� 'E� 1 Y/ `.^L'/� _TITLE II DATE: PLOT PLAN)DRAW TO SCALE)SCALE 't* - 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTUNE6 AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. 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. J .;_ . FOR DEPARTMENT USE ONLY AFPUCATION ACCEPTED BY C >a�.i►r�.OAti� DATE: r- AREA: 7, TANK,PT OR SUMP INSPECTION By DATE / / FINAL INSPECTION BV DATE / l J^9 ADDITIONAL COMMENTS: ACCOUNTING ONLY: NDI FACT PE CODE FEE INFO AMOUNT REMITTED CHEC KABN RECEIVED BY DATE M/FERNY MIMM INVOICE! +Z'2. .a�. v a b3 2