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<br /> APPLICATION FOR LIQUID WASTE PERMIT
<br /> AN'JOAaUIN COUNTY PUBLIC HEALTH SERVII,-M)
<br /> ENVIRONMENTAL HEALTH DIVISION IF
<br /> P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.0388
<br /> (209) 468-3420
<br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> I, {Compkte in Triplicate}
<br /> 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
<br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER
<br /> 9-1110,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.
<br /> JOB ADDRESSIDR APNN
<br /> S220 LOT/ �a. k' CITY �'�"R-•��� '` TS LOT SIZE
<br /> OWNER'S NAME__ i�" ADDRESS PHONE
<br /> ' ` � ' '3 C
<br /> CONTRACTOR ( t3_� ADDRESS/�d /.-i��C+�-y�U 7 GJ3 LIC/ � PHON
<br /> SUB CONTRACTOR ADDRESS LICN PHONE
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION
<br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)f 1 HOW MANY
<br /> Application 0
<br /> INSTALLATION WILL SERVE: j,RESIDENCp0d ?ICOMMERCIAL 11 OTHER 13
<br /> 'j n
<br /> NUMBER OF LIVING UNITS: h NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:
<br /> CHARACTER OF SOIL TO A DEPTH OF 3 EET: ;i PITISUMP SOIL CHARACTER: WATER TABLE DEPTH
<br />- SEPTIC TANKIOREASE TRAP II 0TYPE/MFG r&f,'-IZt tC �/L CAPACITY T2-zD NO,COMPARTMENTS
<br /> PKO TREATMENT PLANT❑ DISTANCE TO NEMEBT: WELL I FOUNDATION PROPERTY LINE
<br /> ,i
<br /> UFT STATION 13 SIZE:, TYPE OF PUMP 690 IL�EPARATOR{ENCLOSED SYSTEM)
<br /> LEACHING UNE 110 NO,&LENGTH OF LINES tri �a � ' DISTANCE TO NEAREST:WELLIttP,Y FOUNDATION 16 Y PROPERTY LINE �n r
<br /> d
<br /> FILTER BED ❑WIDTH LENGTH—� DEPTH ;U DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> MOUNDED ❑WIDTH LENGTH DEPTH `!' DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> yp
<br /> , i
<br /> SEEPAGE PITS DEPTH ms's~ -)SIZE 4,712- r NUMBER II" Z. `DISTANCE TO NEAREST:WELL !p& FOUNDATION ,aT
<br /> A3PROPERTY LINE le.
<br /> SUMPS. ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE f
<br /> DISPOSAL.PONDS ❑WIDTH LENGTH DEPTH iS DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> I 1 �
<br /> 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
<br /> 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 V40W FOR WHICH
<br /> 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
<br /> SUS-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
<br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$. COMPLETE DRAWING BELOW. I
<br /> SIGNED X 'I _ TITLE:^ �.. T.,DATE:
<br /> PLOT PLAN{DRAW TO SCALE)SCALE 'to
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<br /> 1.'NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY.'p 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED
<br /> 2.:OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. ij, EXPANSION OF SEWAGE DISPOSAL SYSTEMS,
<br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND P'ROP'OSED STRUCTURES, }�� S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON
<br /> ;INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. j F` I{.� THE PROPERTY OR ADJOINING PROPERTY.
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<br /> `..FOR DEPARTMENT USE ONLY Q �o{��''�,`'•`� �7
<br /> APPLICATION ACCEPTED BY ' ``•- DATE: i ' `�` AREA: P
<br /> TANK,PIT OR SUMP 1NSPEC N BY DATE I I FINAL INSPECTION BY DATE 1 I
<br /> AbDITIONAL COMMENTS: -
<br /> ACCOUNTING ONLY: ji AID+) 31 I FAC#
<br /> II 7r
<br /> PE CODE FEE INFO,j AMOUNT REMITTED CHECKVICASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE 0
<br /> oar�� € l oo yct 26 '
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