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APPLICATION FOR LIQUID WASTE PERMIT n4ob SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 7 ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Tripikatel APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN CCOUNTY PUBLIC HEALTH BERVIC 8.ENVIRONMENTAL HEALTH DIVISION. ,t JOB ADDRESSIOR APN# �` ` I , `' Cm /_��- LOTS SIZE� OWNER'S NAM;�ew,if- ]P—"c- ADDRESS rye 1/ �� ,-// I�'PHONE '• 1Z CONTRACTOR -/� (!,r.�V• �.� � , ADDRESS I C !Li�I' ^"11 LI ��' '`-�/ *-� L1CI l �C7S RiONE SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW 1 I HOW MANY AppNoatlon INSTALLATION WILL SERVE: RE/SIDENCE COMMERCIAL 11 OTHER 11NUMBER OF LMNO UMTS: / NUMBER OF BEDROOMS:--- NUMBER OF EMPLOYEES: / CHARACTER OF SOIL TO A DEPTH OF J FEET:yf Ci:"/j—L;)-- PIT/SUMP SOIL CHARACTEI 44 /�a4•LL WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS ►KO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF ��y PUMP � !� ,SAND OIL SEPARATOR(ENCLOSED SYSTEM) 1 LEACHING UNE XNO.6 LENGTH OF LINES j-" \ %,-, Y -."- DISTANCE TO NEAREST:WELL! 'FOUNDATION PROPERTY UNE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED `p❑^WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE ATS �c�l OEPTH N SIZE - �`N NUMBER _DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE N SUMPS 11 WIDTH_ LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 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 OWNEI'D" OR MC AGENT'S 64GNATLW CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH ANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONT NO SIONAT CERTIN THE FOLLOWING:'1 CERT T IN TH PERFORMANCE OF TT)HEE��WORK �FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORK/ N'S CO NSAT N WS O tA.' THE APPUC NT M T CALL 4 NO IV's ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. �� 2 SIGNED TITLE: - DATE: PLOT PLAN(DRAW TO SCALE)SCALE_ to — 1. NAMES OF STREET$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 PROVER1Y. :. .............q..�. AY ... ... ... ..< .. -. .. A .. ;._. .. .. .. .. .. .. .. (\V .... .... 1 � .. .... 1`11 r•' IY AL . :.. . _.. . . . - _. .. t .. r--- j .. - \c9c�� _. n�.... _ l 7 \ �(......�R - C ............. ............................