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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION r- P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.0388 t,J (209) 488-3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOP(M,,E�NT TITLE,CHAPTER 9-11110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNM LO S��\ SG Q T�1�j JQ c,\•C O'�&` .^ CITY,�1 1,0CX� �/� LOT SIZE OWNER'S NAME (,V'C.,,1 �J t.\ CY Z"' ADDRESS 5() AG'14%. t�V` 4 A4w�� 1 Ct"f PHONE CONTRACTOR Cl Vv i.S S e�W S ADDRESS 3 1 1 C� !V � t'��S CJ V1 UC# PHONE SUBCONTRACTOR ADDRESS LIC# 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 TESTW I I HOW MANY App41oetion# INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS:— NUMBER OFBEDROOMS: NUMBER OF EMPLOYEES: ` CHARACTER OF SOIL TO A DEPTH OF 3 FEET: Loo�vwt PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMPSAND OIL SEPARATOR(ENCLOSED SYSTEM) LEAC14NO LINE 1%NO.&LENGTH OF LINES C t\J t DISTANCE TO NEAREST:WELL �A,E"J\ FOUNDATION O` PROPERTY LINE •C FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED -❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION p PROPERTY LINE SEEPAGE PITS KDEPTH_7, SIZE--- IZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION O t PROPERTY UNE SUMPS ❑WIDTH LENGTH jL" 'PTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 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 TI4E FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIG RE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO Q WORKMAN'S COMPE ATIO LAWS OF CALIFORNIA I(cq( • TTHHE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REI1Q�UIRED INSPECTIONS. COMPLETE DRAWING BELOW.SIGNED X TITLE: ` O DATE:gq 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. t 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. V1 I I I I --N— I I I � III � I i I —79::___ hV — B - - — I I. +.. . - - - - q - - G n I f -----lf��4Lv wdl.yi m ° _ I�vl I7_; - -- - — :11 �99� ..I �w • •u\�7A i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY C (-/`.ter DATE: A.Z 9. AREA:--z, //�� TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY ��U1:u DATE L7 I /b I yk� / \ ADDITIONAL COMMENTS: �2-v ;•Z.,-,i ACCOUNTING ONLY: AID# FAC' PE CODE FEE INFO AMOUNT REMITTED CHECK#/ ASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE#