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APPLIIJ.■,.,jN FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 962010388 (209)468-3420 NONREFUNDABLE 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 WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI `J/ L7 CITY G { ) /` J /j LOT SIZE OWNER'S NAME _ 1�#"� L L�n LCJ�LC,v DDRESS RLONE CONTRACTOR ADDRESS n 9 �/ UCI .} PHONE SUBCONTRACTOR ,d,/ -z ADDRESS /�/J /�[� /1 q?%y z2� UCI,-i�/'S.'7Q PHONE / TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIWADDITION DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PER.TESTI.11 I NOW MANY APWiceaon Ir INSTALLATION WILL SERVE: RESIDENCE QK COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITS:NUMBER OF BEDROOM.: OJJO��MM�.: 3 NUMBER OF ETMPLOYEEA: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: A.SED�CTTXPIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS C WO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑pSIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) �J :4 LEACHING UNE Py NO..LENGTH OF LINES 3 Ifo%r" DISTANCE TO NEAREST:WELL5j.�OUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PIT. ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PDNDa ❑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 UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMKOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." TTHHEEEAAPPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. Cj SIGNED% /', �({� TRLE: ,(A/�i•-Z+is DATE: /0 �— /S KOT RAN(DRAW TO SCALE)SCALE 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 MOPERTY. t)CT:21199, SAN Ie D E3LIC HEkT ~ AL HEALTH 6'!- S .... YAP A'10' 7c�' —10 ti FOR DEPARTMENT USE ONLY � r APKICATION ACCEPTED BY DATE: AREA: L f — TANK,PR OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: ACCOUNTING oNLY'. AID, FACT PE CODE ME INFO AMOUNT REMITTED CHECK)CASH RECOVER BY DATE BR/—IT NUMB- INVOICE I Y LL I Pd. -3i0.4- L��1dz�r- io SCJ Ua33