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APPLICATION FOR LIQUID WASTE PEgkn SAN JOAQUIN COUNTY QLIC HEALTH SI5kVXES M.IOAQTMT r('tTyVW_ppmENTAL HEALTH DIVISION A-ZONJOAOUIN ST., STOCKTON, CA 95201.0388 y_.. 1209) 469.3420 ��A J OAlIE NOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in 1plieaa) Application is hereby made to the San Joaquin County for a permit-fo construct and/or instalt 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 Divisi Job Address/or AP # Ci6� Lot Size Owners N � �. Address [.�. L/ Phon��i>-��l Contract 1.1� AddressLic#3 28'2 1 (-- Phone7�'� Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITIONA DESTRUCTION I 1 PEBC TEST(@)I I Now many (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Land Use Applieatloa IInstallation will serve: Residence �CommercfaL Other ~ Number of living units:-1- Number .of dro s: Number of employees: Character of soft to a depth of 3 fell= ee r rL Pik Sump Solt Character: Water Table Depth j SEPTIC TANX14REASE TRAP II Type/Mfg Capacity No. Compartments PND TREATMENT PLANT f ] Distance to nearest: Well Foundation Property line LIFT STATION p Size Type of' Pump Sand Oil Separator (enclosed system) LEACHING LINE 11 No. 11' length of lines Distance to Nearest: Well Foundation Property Line 1 1 FILTER BED 11 Width Length Depth Well Foundation Property Line MOUNDED [I Width----,,7 Length Depth Well Foundation Property Line.. \ SEEPAGE PITS � Depth Size Number„�,•,� �� Wet L/00 Foundation D r f- Property rt Line-,5- SUMPS 0 Width Length Depth Well Foundation Property Line 6.1 DISPOSAL PONDS [I Width" Length Depth Walt Foundation Property Line V 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 Licensed agent's signature certifies the following : "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such a manner as to become subject to workmanfs compensation Laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shat' employ persons subject to workman's compensation l ws of California." The applicant must 24 hours Ingay-414of II roqutrad Inepeotions. Complete drawing below. Signed X Title Date:neW 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 2. Outline of.the property, with dimensions and North direction. proposed expansion of sewage disposal systems. 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways,. the property. r adjoining property. and walks. , 7-1 i9q J t RUI ,ES kN VVIR NM NTA HEA TH D'A51T 17 i FOR DEPARTMENT USE ONLY Application Accepted by Area:� Tank, y�t�or Sump Inspection by 66--VDat.*Aaq,0nat inspection by�� a e� Additional Comments: ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED HEC CASH RECEIVED BY DATE OR I PERMIT NUMBER INVOICE# ! 0 5VO I i