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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 (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL 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 DIVISION. "JB ADDRESS/OR APN# 'S s CITY -1F4y ' LOT SIZE.jjD_t'ye OWNER'S NAME (yY� Y�\c�1�2'a;� ADDRESS N PHONE )G�' -ONTRACTOR (LA,' ADDRESS r�G .��-� •i'7�ya LICA' PHONE JB CONTRACTOR ��yy ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION CA REPAIR/ADOITION ❑ DESTRUCTION ❑ 10 SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(*)I I HOW MANY ��GG Applloetion# INSTALLATION WILL SERVE: RESIDENCE 6 COMMERCIAL ❑ OTHER ❑ UMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: HARACTER OF SOIL TO A DEPTH OF 3 FEET`—_ PIT/SUMP SOIL CHARACTER:-C �;_3- WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP EI TYPE/MFG e0t-k �I�1[< CAPACITY Arj'!7;'0 NO.COMPARTMENTS o� 4 -XG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL -:�Z 1 FOUNDATION JS PROPERTY UNE�� UFT STATION❑�S�IZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) ZEACleNG LINE i`f NO.&LENGTH OF LINES � �C �� e DISTANCE TO NEAREST:WELL�C/ / FOUNDATION 3J ( PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 1` 'SOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL �71� FOUNDATION PROPERTY UNE \/^` �EPAGE PITS DEPTH SIZE �P NUMBER DISTANCE TO NEAREST:WELL/ FOUNDATION tv t7 PROPERTY UNE�T \ SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE ISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 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 r` AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FORWHICH 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 JB-CONTRACTING SIGNATU CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO /ORKMAN'S COMPENSATIO WS OF CAL ORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. I \ SIGNED X % TITLE: fJV�1� �--kE- DATE: � V PLOT PLAN(DRAW TO SCALE)SCALE 'to i. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED C 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. n 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. s ........ ...... .. i. ,.. � .` ... li » . ........ - .. .