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APPLICATION FOR LIQUID WASTE PERMIT S JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 (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 )OAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# 1�l C) (�'� �s CITY 1{�i'�-1F•�-�•G�� LOT SSIZE_jZ)_11j-�,C JWNER'S NAME -ADDRESS PHONE CONTRACTOR (i>tf� tC: ADDRESS VT' LIC# --1>CXS--j7 I PHONE 3UB CONTRACTOR ADDRESS LIC# PHONE rYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(s)( 1 HOW MANY .,��qq Application# 'INSTALLATION WILL SERVE: RESIDENCE L7 COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS: � NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OFF33 FEET(,•_. PIT/SUMP SOIL CHARACTER:Sf,,1'# WATER TABLE DEPTH (+u SEPTIC TANK/GREASE TRAP 91 TYPE/MFG CX9/1c CAPACITY NO.COMPARTMENTS ca•� PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL -4570' FOUNDATION /S PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) 7 LEACHING LINE 0 NO.&LENGTH OF LINES -j )e- DISTANCE TO NEAREST:WELL z�! FOUNDATION 730 PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE _ (� MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION / PROPERTY LINE H SEEPAGE PITS B DEPTSIZE C(J NUMBER 5 DISTANCE TO NEAREST:WELL I FOUNDATION fyo� PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE / V 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:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WOW FOR WHICH V THIS 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 SUB-CONTRACTING SIGNATU CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIO WS OF CAL O NIA.'�THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. —t/WJE/ / \ SIGNED X TITLE: ::h0VjfdZ C_J-•��- DATE: '3 -Q/ • vl 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. 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. v, ..i... ..........- .. .. .. .. .. .. .. INS .. .. .. .. .. - - .. .. .. .. .. _. .. .. ... . . .