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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468-3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION I6 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.-�oD x,, �� I JOB ADDRESS/OR APN# t - CITY /iiy(_ l LOT 61/Z/E�I > `OWNER'S NAME A DRESS L PHONE 02 1<1 CONTRACTOR LIC# PHONE (� SUB CONTRACTOR - ADDRESS UC# 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 TEST(*)( 1 HOW MANY Application# tr/ INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL 11 11 El NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: � NUMBER OF EMPLOYEES: ^� 4z CHARACTER OF SOIL TO A DEPTH OF 3 FEET: / PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS N PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT PE - STATION❑ . LIFPUMP SAND OIL SEPARATOR SYSTEM) 77LEACHING LINENO &LENGTH OF NES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE R� v FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE (� MOUNDED ❑VOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PIT& SIZE_ '1 ((Tt�NUMBER _.DISTANCE TO NEAREST:WELL h9D FOUNDATION��PROPERTY UNE SUMPS VC-IT"1. LENGTH DEPTH DISTANCE TO NEAREST:WEAVL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE -1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOWS 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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWCMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIG URE IFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOWS FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPS SATION OF CALIFO THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X E=�-� TITLE: DATE:<�—C>2L> � e- 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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DWVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. `......i... .�.... ...' .....i.....'....E ... :. ..;......i ..;... . .. .. .:. ... i_. :.......... .. , .._:... .i .. .. .. ...... ..... .. .. .. .. .. �� ... :. ..:.. .,. ... ...... i _.-..: :.... .. ._ i.... ... .:.... .. .. .. .. .. .. .....i. .:......:._..___..... _[.. .. i . law .. .. . .. .. ... ..... . Q ..... ir■ _:.