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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.0388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��-7 (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER A9-1110.3^1AND THE STANDARDS OOC-7120L, F�SAN }JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. IB ADDRESS/ORAPAPNNwZ, i�'g`Z 16) c�O W j 1�, O `'✓/ /2 0 (, CITY ��-qp ��G•.,32- TTSIZ-Er3O�- OWNER'S NAMEM1 1'�Z-1��p�,r��n Q� ) SST ADDRESS L p�, �, T -7'59 r '5 p PHONE-2-409 -7 10'9 � )NTRACTOR M-C`� A-4 r' { ��-{ TVVC�ADDRESS �S0 &I MO YJb -P—v, UCN /S9 S-1 S PHONE*5G I-W-SZ- 'B CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION IM REPAIR/ADDITION ❑ DESTRUCTION ❑ 0 SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW[ 1 HOW MANY 11pv�I Applloetion l INSTALLATION WILL SERVE: RESIDENCE 19 COMMERCIAL ❑ OTHER ❑ AMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS: � NUMB9i OF EMPLOYEES: � _IARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: / WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ®TYPE/MFG l�a��w� r CAPACITY I,(OOO �Q.�W r0.COMPARTMENTS G TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL (oOf> FOUNDATION 'S I PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH INO LINE la NO.&LENGTH OF LINES '-)— L410.1 DISTANCE TO NEAREST:WELL E{-FOUNDATION X0 I PROPERTY LINE -751 _ FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE )UNDED ❑WIDTH y c LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE �7 ..cEPAGE PITS 91 DEPTH L/.J SIZE a(O" NUMBER_ DISTANCE TO NEAREST:WELL 0`-f- FOUNDATIONS PROPERTY LINE / S SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE :POSAL 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.HOMEOWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH "'IS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR B-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO )RKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR /ALL LRRE_QUI,REEDD)INS�PEC�TIO-NQS-.. COMPLETE DRAWING BELOW. �-7 V �NED X TITLE: C151j L-K-fc�ly �� DATE: 01 jvsj 02-- I 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 j 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 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. ...... t._ -J_.. ............... ..._. .. .. . T 1 .:... .....:.... .. _ N . . v, moo° ... ... . .. ................... .. .. _ .. �{L yy .. .. .. ............................. t7' .'. ... ... ... ..do �_T o--n ... PAYM E!4c [ .... y .7I,.l�� .. ; ...... A N..JOAQUIN L Lur PUBLIC HEALTH SER'vICLS