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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH ')ICES ;? ENVIRONMENTAL HEALTH DIVISI.,,, P.O.BOX 388, 445 N.SAN JOAQUIN ST., STOCKTON,CA 962010388 (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete 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 DEVELOOP-MEE'NNT�TITLE.CHAPTER 9-1110.3 9-1110E((.33 ANI THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEAL(TTHH,SERVICES,ENVIRONMENTAL HEALTH DIVISION. ` JOB ADDRESSlOR APN#(j//J�L//0 V nt• Y QO,�VX j�-• C{ C,I,T,/lY l�I�EE✓t.", LOT SIZE Z r�U OWNER'S NAMECRl�v�l!"y'(�]�L''..1 Fr h1�i ,�r�1, ADDRESS(('S 1 1 l.• �i�hXC1t I�IJ' 3( �s IT'7 PHONE R CONTRACTOR -7 G Jam/ ADDRESS LIC# PHONE SUBCONTRACTOR ADDRESS LIC# PHONE .f TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADgTION ❑ DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW[ I HOW MANY APdmeno^# INSTALLATION WILL NUMBER OF LIVING UNI�T6E�_ENl1M CBE COMMERCIAL ENUMBER OF EMPLOYEES: Q CHARACTER OF SOIL TO A DEPTH OF 3 FEET: P�IT/SUMP SOIL CHARACTER: p /5 WATER TABLE DEPTH 1 SEPTIC TANK/GREASE TRAPTYPE/MFG LC I-V CJ`j•M'LCF d CAPACITY �r(-_P( 1 NO.COMPARTMENTS 164 PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: ELL !TOO 7:7 FOUNDATION_ PROPERTY LINE a,S -f UFT STATION❑ SIZE TYPE OF PUMP h SAND OIL SEPARATOR(ENCLOSED SYSTEM] w U Y ]r LEACHING NE 75L NO.6 LENGTH OF LINES b}`� L4 r DISTANCE TO NEAREST:WELL FOUNDATION Li 0 PROPERTY LINE FILTER BED /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED �tt❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DEPTH SIZE NUMBER J i SEEPAGE PITS 7cL _DISTANCE TO NEAREST:WELL FOUNDATION I _C PROPERTY LINE '� J SUMPS /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PON06 ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APF'IJCATION 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 THEWORK FORWHICH 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:'I 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 REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. - SIGNED ( [,1LC 66 AC- -LZ-`j-TITLE: �IN f�-+L/� DATE: r Nf V PLOT PUN(DRAW TO SCALE)SCALE r 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. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXI �%�" IOP„�S STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,OEIB/ A S,ANbIW/FLKS:i THE PROPERTY OR ADJOINING PROPERTY. P'ALIC HE:ALI FI SERV!CF5 �Nlrl!�C3�dl il�TlAM�iEAU Cf4'ISIV; _— — -� __ 1 _ t -- _ r ; ...... '- �- FORM DEPARTMENT USE ONLY APPLICATION ACCEPTED BY'-I-,/ �T� -�I/ DATE:�I I r �% AREA: p TANK,PIT Oft SUMP INSPECTION BY DATE i FINAL INSPECTION By ( �/2/lam-(' �� ] DATE /SL" G ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC# P..E CODE FEEINFO AMOUNT REMITTED ECK CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE# /L_y' ck- I -z-( I {I i