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APPLICATION FOR LIQUID WASTE PE""IT SAN JOAQUIN COUNTY PUBLIC HEALTH ICES ENVIRONMENTAL HEALTH DIVISIM' P.O.BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 952010388 (209)488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CGmpWtB in Trpbuu) A ATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMR TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAAF rER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SER/VICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSPOR APE(/ ME/I5 I C ?I j+!"- `�C - CITY`-�'LQ"-N LOT SIZE OWNER'S NAME:Z&/U I .e,7-J AA&—,- ADDRESS /"/+� J PHONE CONTRACTOR ADDRESS / Z/ C_ � �•�� 'r - LIC/�TZ S 1110 NEV3 BUS CONTRACTOR ADDRESS LICE PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIPJADDITION❑ DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WTHIN 200 FEET OF BUILDING.( PER.TESTI.)I I HOW MANY Appllwtlon t INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITS:NUMBER OF BED/ROOMS: NUMBER OF EMPLOYEES: CM OF 601E TO A DEPTH OF 3 FEET: �U( { PITfSUUM.,P SOIL CHAAACTEfl.'��`�,/��/cy` �-WATER TABLE DEPTH FPTiC T GREASE TRAP ❑TYPE/MFO L•n�/lC� �y-��- CAPACITY/ I ([9C'3 NO.COMPARTMENTS TM ENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION `] PROPERTY LINE}�Q NFT STATION❑ SIZE TYPE OF PUMP,/ SAND OIL SEPARATO (ENCLOSED SYSTEM) LEACHING LINE �/.L/�.1/I ND.i LENGTH OF LINES �`7O/ �• "O• ISTA��d NEAREfa2T:r�ELL FOUNDATION PROPEfT'LINE FILTER BED LJ WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE UJl MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE ATB �bEPTH ��5, SIZE��NUMBER_ DISTANCE TO NEAREST:WELL/._� FOUNDATION C PROPERTY UNE G SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONOS ❑MOTH LENGTH DEPTHINSTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OFTHE SAN JOAQUIN COUNTY.HOME OWNER LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OFTHE WOM FORWHICH .L TH?\E MITDSUED,I SHALL NO Y ANY PERSON IN SU A MANNER AS TO BECOME SUBJECT TO WO WMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR 1 T� 6VTURE RTIFIES TH LLOWING:'I CE I THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO A, WAN'SVSAT N 6 OF CALIFO IA.- TH A T MUST CALL 24 HOURS IN ADVANCE F/OOR�.ALL REEQUREDDIINSPECTIONS. COMPLETE DRAWING BELOW. �/•'J 4 N % \` TITLE:` 9rA I M/.V/I't DATE:J L Ja ` ROT PLAN(DRAW TO SCALE)SCALE 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 EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WTHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. If L. 6 € _...a.- .......a...,.......4......, a ........a ...... ...... d.._.......b....,... ... .......o..._p.. V .. :......a...... �\... .... .....t.....r'......e a ...... V4V .. .. _ ......i......e. . .....s._ .. �La"x25 P• +s :.....;......i...,��...._ ...... l_ L r 1` 1 / {vt hE{F NVIR4 FOR�DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ITAyIC 17 DATE: AREA: RSUMP INSPECTIOBY N l F FINAL INSPECTION BYS'�-G: �O R�✓I QATE J! / V ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID, FAC♦ K CODE FEF INFO AMOUNT REMITTED HE (CASH AECEVEO BY DATE MR/—IT NUMBER INVOICE, 1 bqU 0-7