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11.3° _. APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a RO. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (209) 488-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIOED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 1 10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESS/OR APNA �(//�I�/ /✓n' /`�• �� >��'�� + CITY Lf�C�� LOT SIZZE+/ 12-f1 OWNER'S NAME �'`t k, V,u.{,�.[�_ ADDRESS__ JPHONE ( ` /� CONTRACTOR, /v-�� . ��- ADDRESS/'?f/ �fI(.i,�((J/• �i>/ J✓ LIC A'� _PH0NEgt1h �,J-�Y 3 SUB CONTRACTOR ADDRESS UCO PHONE TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 1 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(s)( I NOW MANY Applloatlm�I INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER ❑ , 1 _ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS- NUMBER OF PLOVEES: C OF SOIL TO A DEPTH OF 3 FEET: /?f( PIT/SUMP�SSUyUMP SOIL CHARACTER: �y WATER TABLE DEPTH EPT1C TANK/GREASE TRAP ❑TYPEIMFG CO1'V'IZ)__jjjj..��( CAPACITY ��L"DD G/1'-s/ NO.COMPARTMENTS W .PJ(O-TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE V� _ UFT STATLON❑yyy��SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) y LEACHING UNE �S.l_NO.b LENGTH OF LINER �r/ \ / Y �aD �/ 2- DISTANCE TO NEAREST:WEL FOUNDATION/L%' PROPERTY LINE "1, FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE r�S SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE ')HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THN NK; ORK MILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. OME OWNER OR LENB D ENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IS I SHALL NOT EMPLgy- PERS !M SUCH A►AA NER TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA." CONTRACTOR'S HIRING OR SUB-CONT I SIG TURF CERTIFIES'THE FOLLOWING: 1 CERTIFY T AT IN T PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PER90NS SUBJECT TO wow M 'S COMPENS N WS O LIFORNIA.- THE ANT UST CALL 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$. COMPLETE DRAWING BELOW. � `�'v l DATE: ✓" ^` J SI ED X_ TITLE:�- LRE PLOT PLAN(ORAW TO SCALE)SCALE 'to 1. NAMES OF T ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIME)ISIONS 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,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. .... .. Vol,