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�- APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 38B, 446 N.SAN JOAQUIN ST.,STOCKTON,CA 95201-0389 1209)468-3420 NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CsnpbN Is TrylWtsl Application is hereby made to the Sen Joaquin County for a Permit to construct end/or Install the work described. This application is made In comp iart e with Sen Joaquin County Deve I opmcnt Title, Chapter 9-1110.3 and the Standards of Sen Joaquin County Public Health Services, Environmental Health Division. Job Address/or APNM Qef 3 S3 n Nrfowu 99 cit,-L92t )T_ Lot size �top?��lc''Rcs�� Owner's Home-13i�finrxt trr1] -F- F- Address �^ Phorg-3 ,+-2n., Contractor arc !f�->R13C Address 1a$$ 1 �erK�on B�A LicM ' S'lZ1 Phone.3G4-343'i Cub Contractor Address Lic# Phone TYPE OF SEPTIC WORN: NEW INSTALLATIDN I1 REPAIRIADOITION M DESTRUCTION II PERC 11811.)11 Hew any (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) land VH A1Pliutba/ Installation will serve: Residence_ Commercial Other_ Number of living unit.,_ Number of badroomsl Number of snploy.os:_ Q�� 1 Character of soft to • depth of 3 feat:, Pit/Sump Soil Charactar:�c2JL—!S/-Ired Water Table Depth�)OL F SFPTIC_TANIUOREABE TRAP I) Type/Mfg r.-,rK.2�f FlCspecify Compartment. PKG TREATMENT PLANT [ I Distance to nearest: Well Foundation Property line LIFT STATION[) Size Type of Pump Sand Oil Separator (enc lased system) LEACHING LINE 44- No. S length of ifnes _ Distance to Nearest: Well;sa, FoundetfogtaZ Property Line `S cP l"-& Veil Foundation Property Line r[ FILTER BED [] Width_ Length_Depth � 9J MOUNDED I] Width_ Length_ Depth_ " " WeIL Foundation_ Property Line (rJ SEEPAGE PITS Pr Depth .)Size Humber-3- " l(WelFound.tion -SLL_Property Line-Y) r Z SUMPS II Width_Length_ Depth_ " " `Yet[ foundation_ Property Lim—1, DISPOSAL PONDS it Width_ Length_Depth_ " " Well_ Foundation Property Line p, fi I hereby certify that I have prepared this application and that the work will be done in sedordence with Sen Joaquin County h Ordinances : II State rt Laws, and Rules and Regulations of the Sen Joaquin County. it i owner or licensed agent's signature on in lea the following ' . "1 certify that in the performance of the weak for California." a i this permit is issued, I shad not employ any person it such a roamer es, to hewing subject m workman's compensation laws of Cal for which Con permit(16 hiring or sublcontracting sigons sub re certifies tons the following: •I certify that in the performance of the work for which this permit is Issued, 1 shall employ germane subject to workraMs.) compensation laws of California." TM applicant most x0 2y24/hours to ads far s0 rsquHJ Inspection, Complete drawing below. Signed X JIM // l ' Title: hJnee Date: E/- 7-3S- PLOT PLAN (Draw to Scale) Scale a to 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or 2. atlim ofthe property, with dimensions and North direction. proposed expensf on of sewage disposal systems. 3. Of mensfoned outlines and I...tic. of all existing and proposed 5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways, the property or adjoining property. ' and walk.. l 6114 Sf I[O.� _� n Le' a S PA YMC-EN7 s IE d 'ow rY \ I NM-N7A HE LTH )IVIS CN ff FOR DEPARTMENT USE ONLY Application Accepted by - Date: -7 Area: a/ Tank, Pit or Sump Inspection by Date / / Final Inspection Additional Comments: N.w aAfl wa SyS ACCOUNTING ONLY: AID# FAC# / PE CODE FEE INFO A UNT REMITTED E N ASN RFCMVEO BY tlaiE SR I PERMIT NUMBER INVOICE#