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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.0388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complata 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 DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNN \ ) ��,� 1 CITY M ( i LOT SIZE _! i�X 'A1 < C,L/ b ��//LA �jirt �lJ, PHONE OWNER'S NAME �-r ADDRESS_ �,7 B^s n // 7 CONTRACTOR I - ADDRESS / C C� C�..F'�T..�LA-C� UCN��PHONE ! WF-5/-�O SUB CONTRACTOR ADDRESS UCN PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION& DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.1 I I HOW MANY �/ Applic.0-t INSTALLATION WILL SERVE: RESIDENCE T COMMERCIAL ❑ OTHER ❑ NUMBER OF UMNG UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A-DEPTH OF 3 FEET: PIT SUMP//S77OIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TMP ❑TYPE/MFG� N L.�J_�oGAPACITY J �n NO.COMPARTMENTS �/ J1 PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑�SIIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) �l LEACHING UNE !gJ NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE S SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE r r SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE VAR d9POSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE r I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION 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 UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH cl 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 SUBCONTRACTING 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 CO PENSAT$ON LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL 'REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW.`r SIGNED X TITLE: DATE: 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. 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,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. /+L {1 _ _ aA-1 .... ..... .. ... .._ _ J - PAYMENT. j SEP 1 5 1995 SAN JOAGo iv