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` APPLICATION FOR LIQUID WASTE PERMIT SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) -APPLICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENTT TITLE,CHAPTER �9-1 110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR AAAPNI ^� / ✓" 7- h ` CITY `7� LOT SIZE FIt"�c _OWNER'S NAME 4j\cD L�-+��-� ,C'A- ADDRESS ,CJ j ii 7C ��'(ZL. C-i? �c-�- PHONE . CONTRACTORADDRESS 12 i (5:/j 1 7UCI OE �1 7y tT / � SUBCONTRACTOR ADDRESS \ UC# PHONE ITI TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDO DERTRVCTM\R (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF B ILDING.) J\ PERC TEX W I 1 HOW MANY _ \��/ APdl—tion 0 ill INSTALLATION WILL SERVE: RESIDENCE LLl COMMERCIAL ❑ OTHER ❑ V(' NUMBER OF UVINO UNITS: f NUMBER OF BEDROOMS: -1 NUMBER OF EMPLOYEES: j CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER:/--f WATER TABLE DEPTH SEPTIC TANK/GRFASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE NO.3 LENGTH OF LINER _l—J O '/t_� DISTANCE TO NEAREST:WELL O FOUNDATION �� PROPERTY UNE _� V RLTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE v MOUNDED ❑WIOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE S c� SEEPAGE PITS IDEPTH �-�j � SIZE 7 7 l.% NUMBER�_DISTANCE TO NEAREST:WELL�d�J FOUNDATION /00' PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES O AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER R LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH ..1 THIS IS ISSUED,I S EMPLOY ANY PERSON IN 8 MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA." CONTRACTOR'S HIRING OR SU -CONTRA NG SIGN TURE C RTI 3 TME FOLLOWING:"I ERTI THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO W PK MAN'S CO PE SOF ALIFORNIA.' T CALL 24 HOURS IN ADVANCE FOR ALL REGUIREO INSPECTIONS. COMPLETE DRAWING BELOW. CT SIGN X TITLE:_L C��t-'7�L/� CVTl� DATE: i v PLOT PLAN(DRAW TO SCALE)SCALE to _.1. NAMES OF STREETS OR RO S 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. 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAY8,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. A 410. "3 P max'- v