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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES �/C ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 96201.0388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complata 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 ADDRESS/OR APN# /- ^sQO 7 Q A>Q()C-1 CITY �j��E�� LOT SIZE OWNER'S NAME l 1 LLL'r�� T I?LA- / Xi ADDRESS /`)l}/J ,E i � L'LQ bIC Iir,.Q PHONE S/0 CONTRACTOR ADDRESS ^/� n UC# .yPHONE SUB CONTRACTOR /Qj k Z� ;91Z. �� ADDRESS TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑+- 11 (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIO f I HOW MANY AppBostlon/ INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPL EEE: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER T DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG PCAPACITY �w� NO.COMPARTMENTS PKO TREATMENT PLANT ❑ INSTANCE TO NEAREST: WELL �FT FOUNDATION /- / PROPERTY LINE�FT LIFT STATION❑ SIZE TYPE OF PUMP �S�ANND OIL SEPARATOR(ENCLOSED SYSTEM) /� T LEACHING UNE NO.8 LENGTH OF LINES—/# '- �� / • DISTANCE TO NEAREST:WELL TUN 10) T O��pERTV UNE - FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS 11 DEPTH— SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SI1MOa 11 WIDTH— LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 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 CERTIFYTHAT 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 CAUFORNIA.• 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 COMPENSATION LAWS LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X V� ♦ ��1 TRLE:_&j��J DATE:__ PLOT PLAN(DRAW TO SCALE)SCALE •tc 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, EXPANSION F SEWAGE DISPOSAL SYSTEMS. INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, S. ONE HUNDRED FIFTY FT.ON -- — THE PROPERTY OR ADJOINING PROPERTY.O Q: ..., PAYMENT _ ....:......:... .:...... :... :._..........> ......... . _.MAR 199 __ .1 OUIJTY NlI3l1t iEILTN SERVICES ,... �� ._ . _. ENYIRONMENTAI HEALTH NISIO _ 1. .... _ .... 0 1 -- I . 806 r-r ,- - - - (� fo I .. Ab d ... : d.- � � � ........... ..... . _. IV r:; FOR DEPARTMENT USE ONLY Z APPLICATION ACCEPTED BY DATE: AREA:� a TANK,PfT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION B DATE L� ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED ®/CASH RECEIVED BY DATE SR/PERMfT NUMBER INVOICE 9