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iPPLICATION FOR LIQUIO WASTE PERMIT SAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.M. BOX 388, 445 N. SAN'JOAQUIN ST., STOCKTON,CA 85201.0388 {209] 468-3420 ' I WON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (1omplsto in Tdplieatn) j APPLICATION IS HEREBY MADE TO THE SAN JOAQUINCOUNTYFOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 1S MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3�A)ND THE STAN'D]ARDS.OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# --CITY ..�I LOT SIZE„'/��. .�,. ADDRESS PHONE ' OWNER'S NAME ��`� 2. CD s J yC 5' L ��o� ,5w7C-aoQ UCx Pl�o �S/G 0184 CONTRACTOR ADDREBS " 5 SUB CONTRACTOR 'i ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION• DESTRUCTION 'I PERC TESTW 1 1 NOW MANY ' IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF,BUILOING.I I .,I Application-i II i INSTALLATION WILL SERVE: RESiDENCE� COMMERCIAL ❑ OTHER ❑f' - 31 NUMBER OF LIVING UNITS:—/—L,/ NUMBER OF BEDROOMS: 3 NUN19Eit OF dHIPLOYEEB:,,�„^� CHARACTER OF SOIL TO A DEPTH OF 3 FEET: ' PITISUMP SOIL CHARACTER: WATER TABLE DEPTH - SEPTIC TANK/GREASE TRAP ❑TYPE =1 ��CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT 11DISTANCE TO NEAREST: WELL ,, FOUNDATION PROPERTY UNE LIFT STATION❑JW '° TYPE OF PUM' SAND 01}SEPARATOR[ENCLOSED SYSTEMI LEACHN4 UNE .Rid NO.&LENGTH OF UNES' ,~S�-� DISTANCE TO NEAREST:WELL / FOUNDATION , PROPERTY LINE FILTER BED ❑WIOTHJ LENG'H DEPTH " DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED [3WIDTH; LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE NTS DEPTH _BIZE1 Y �--NUMBER__,L__--DISTANCE TO NEAREST:WEkl f�13 FOUNDATION �' PROPERTY UNE—75-7-- '2 7� SUMPS ❑WIDTH LENRTH DEPTH II, DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS 13 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 ANO STATE LAWS,AND RULES 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 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:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA'" THE APPLICANT MUST CALL,24 HOU"IN ADVANCE FOR ALL REQUIREP INSPECTIONS. COMPLETE DRAWING BELOW. SIGkED X .i1 TRL.E: DATE: � PLOT PLAN(DRAW TO SCALE)SCALE 'to t. 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. I� EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 'U 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. €G THE PROPERTY OR ADJOINING PROPERTY. -- -- .. ............ .. -- k4 t L{ .. .... tG... .. .... ,,.., fi s ., C a ... r. .. j.o c I t""NT I A....... . ..... .,... . ........ ..... . I� d � .. .. _:. .... 19 I'. � d - s S Ta �� - F' tf, .I. *,I'�1�1 P :... .. H �Z' i p EN 2UN�v1' f� 1L F !»a L7 k� W :1 FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTER BY C DATE: Z AREA:-I- BY f TANK:PIT OR SUMP INSPECTION BY LATE ! ! FINAL INSPECTION BY DATE !�� ! / `G c ADDITIONAL COMMENTS: � II .00D[t- Q G- S�'►"L 4 41ACCOUNTING ONLY: ,F TID# FAC# /a7[ fx PE COPE FEE INFO 'I.AMOUNT REMITTED CHECK/!CASH RECEIVED BY DATE SR!PERMIT NUM6t3i INVOICE#