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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED iCempleto in Tripl'leatsl APPLICATION IS HEREBY MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMEN'TTTnLF.CHAPTER 5-11NOTHE STANDARDS OF SIA JOAQUIN COUNTY PUBLIC HEALTH SERVIC B.ENVIRONMENTAL HEALTH DIVISION. ;7",j JOB ADORESSIOR APNN A t • �I."� G CITY t✓+J LOT SIZE_l IICI P� OWNER'S NAME !�Z � 11P-tLr ADDRESS PHONE CONTRACTOR S A7fL4 {w�,r ADORE68 �P�'nJ +Q< LIC '4 7 – rel BUD CONTRACTOR ADDRESS UC' PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION Or REPAIRIADDITION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.1 PERC TESTiol 1 1 HOW MANY � Appllmdon' INSTALLATION WILL%VRVE: RESIDENCE COMMERCIAL toy OTHER❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH T-+ SEPTIC TANIIOREASE TRAP ID TYPEIMFO CAPACITY '�`+ NO.COMPARTMENTS_, ._ PKO TRFATMENT PLANT❑ DISTANCE TO NEAREST: WELL�,S 4l.?� FOUNDATION L.O 1 PROPERTY LINF c,± UFT STATION❑�fyySIZE TYPE OF PUMP SAND OIL SEPARATOR 1ENCLOSED OYBTEMI LEACMNO UNE 0 NO.&LENGTH OF LINES Z L�O r _ 018TANCE TO NEAREST:WELL '"Z�� FOUNDATION 2C1--PROPERTY LINE;' FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I SEEPAGE RTS '®DEPTH 'Z S _SRE J 5CS NUMBER„DISTANCE TO NEAREST:WELT.—T&Q1 FOUNDATION��PROPERTY UNE. BUMPS ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL FONDS 0 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 WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING.•1 CEHTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1$HALL NOT EMPLOY ANY PERSON M SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SKINATURE CERTIFIES THE FOLLOWING'•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I$ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA."THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. f � f SIGNED X . TITLE: C A, -- DATE: "/ �`�• - ':�K _ PLOT PLAN(DRAW 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. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUbINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK$, THE PROPERTY OR ADJOINING PROPERTY. .............. ......., - - - .. ........ ..... ....., .. .. _ .. .. .. Y'� -_ .. S .. .. 60 RAW- 9 .. ..; .F ...:.... SEP.... 9B. .:...... . . �IF!{,NT. � 4 : � �1..1C ERL:`fIiS�HVII � .. - Ts ., .,. v;... N'L TA! IiFAl } 7 -- /s�j�[ ..:..............:...... �j O ARTMENT USE ONLY �' AREA: APPLICATION ACCEPTED BY "�'L DATE' �j TANK,PIT OR SUMP INSPECTION BY DATE I I _FINAL INSPECTION BY DATE r- 128 J WFL�u�� COMw PE ACCOUNTING ONLY: 9c- PE FD' FAC# f CODE FEE INFONT RIMITED HEC ASH RECEIVED SY Tw TE BR I P99IV T NUMBER INVOICE' �I�, ZS ��' 8 Pub.Health Serv.-Enviro.174{3196}