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APPLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES �1 11/060 a ENVIRONMENTAL HEALTH DIVISION RO. BOX 388, 31M EAST WEBER AVENUE, STOCKTON, CA 95201-388 �b (209) 488.3420 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 AN THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN/ Q 1 Z- I Go ! * 8 c�ZSStd Eos Som lakbITY �7aGlCTIIlJ OWNER'S NAME BI U bEtJ 5-1 ADDRESS 3.16p ti-T. Q ,� U C)cj). 1_4FAy�ggsytONE LOT SIZE T ' 2 ,/ 7W , . r ZNO q ,/ / ? CONTRACTOR SLJ r�J d' �OG I 1�� ADDRESS_ (�Z LI. (�)L(�SlUN (,N� C.t��( qt PHONE 3W7-37I SUBCONTRACTOR ADDRESS UCS PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION Ff REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW 1 I HOW MANY ' Applltstlon I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALS OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF SEDROOMS: NUMBER OF EMPLOYEES: / 1 CHARACTER OF SOIL TO A DEPTH OF 9 FEET: PIT/SUMP 8011.CHARACTER: LMATER TABLE DEPTH l O SEPTIC TANK/OREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT ❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 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 SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATI 8 OF CALIFORNIA.' THE APP'UCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X �`c-�)1 i, �!/ TITLE: DATE: 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. y qg N w PUSUC HEALTH`SER ICE-$ Ali .t11�/IAUNi1 'I + HEAI_lf-a 1)ft'1$iory ... ... ..... .. ;.;... �traN i QQ ',� , �`OR DEP A��t�J►�(�/\T USE ONLY'AA '�] APPLICATION ACCEPTED BY �J ` "�/'\�'�� V• DATE: 1.;?,[ AREA: TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTIO V DATE/CO7- / ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID+I FAC/ PE CODE FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY DAT SR/PERMIT NUMBER INVOICE I �2 7 _ -�(9t is y