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j^r 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) 468.33420 NON-REFUNDABLE PERMIT EXPIRES I 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 HEALTHSERVICES,ENVIRONMENTAL HEALTH DIVISION. �1 JOB ADDRESS/OR APN# -:. v n CfTY /% � LOT SIZE OWNER'S NAME ✓ ADDRESS PHONE CONTRACTOR 1 ADDRESS /- LIC# PHONE_/. SUBCONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)I 1 HOW MANY Appli—tion# INSTALLATION WILL SERVE: RESIDENCE YrJ COMMERCIAL ❑ r OTHER ❑ NUMBER OF LIVING UNITS:_/ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITIS—UMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ElTYPE/MFG_ 1 S• 1 h CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL L C4-� FOUNDATION FROPERTY LINE UFT STATION 11 SIZE- TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM)LEACHING UNE IL7 NO.&LENGTH OF LINES // l•'D DISTANCE TO NEAREST:WELL ? FOUNDATION ,3 r_, PROPERTY UNE 1'C FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ^❑/WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE FITS �(J DEPTH = / SIZE NUMBER_��_DISTANCE TO NEAREST:WELL FOUNDATION /-(`'/ PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH_ DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 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 THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH ^ THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR '(V SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWSOF�LIFORNIA.. THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. / SIGNED X ' l i v/C - _ -- TITLE: (y✓vf�1'j.� DATE: f-\ 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 O 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, 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. Al ...... G _ Z �`y V ..... ....... © .. PAYMENT IRE.-EINE[ :'MAY:9 19,5 SAN-JCJAQ�IN GOUN"'. PURLIC.HEALTH 5�RWQES ETNViRC)NMENT�L NF4Lt�t'?fCilSi�r