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APPLICATION FOR LIQUID WASTE PERMIT eAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES- ENVIRONMENTAL HEALTH DIVISION P.O. BOK 988, 304 EAST WEBER AVENUE,STOCKTON, CA 9MI-988 0 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATS ISSUED (Comyiato In Triplicate) APPLICATION 18 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 it JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1110,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �/CK ERS NAME � JOB ADDRESSIOR APN# la - a" CRY ��,....sar, •"• LOT S1;E/L I . [I OWN ' t • �' __ [yy� ADDRESS PHONE IIS ',i CONTRACTORT _�:rADDRESS zov-'2 LIC# PHONEY SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION CfI�„ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIQ 1 1 NOW MANY f� Applloe8on# 4y INSTALLATION WILL SERVE: RESIDENCE I& COMMERCIAL ❑ OTHER ❑ [i NUMBER OF LIVINO UNITS- NUMBER OF BEDROOMS: 3-_ NUMBER OF EMPLOYEES: ti CHARACTER OF SOIL TO A DEPTH OF 3 FEET; 6bkdPITISUMP SOIL CHARACTER: WATER TABLE DEPTH �b t I� SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS E PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP �fL SEPARATOR{ENCLOSED SYSTEM) ` LEACHING LINE ® NO.&LENGTH OF LINES I r DISTANCE TO NEAREST:WELL FOUNDATION zn f PROPERTY LJNE_.,mQ� FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE , f MOUNDED ❑WIDTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE d SEEPAGE PITSk� DEH SIZE ( t NUMBER. j:g DISTANCE TO NEAREST:WELL ]f 5 -,,,_FOUNDATION PROPERTY LINE_' l;y SUMPS 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE r DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE —A fi 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 ClEfMFIES THE FOLLOV41NO:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH G 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 !1[ SUB-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 WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. 1 .I SIGNED X - TITLE: DATE' ' PLOT PLAN(DRAW TO SCALE)SCALE 'to I, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION Of HOUSE SEWAGE DISPOSAL 6YBTFJu1 OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 1 � 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, .. �1. - - rC, .. . 16 .. _ '... s I f .. . ' j. . �.. PAYE . ... ..,..,.. ... ...... SAN JOAQUIN COL1M7Y. m -F ' _ F. ,_�",'-s,:-�----�--=•,,.d �---'-`:-?�-� - -�Nuln6i1NY$LHEA SERVICES: Vs, - 4 .. I - - .. �3 7 ..... . .. ........ ............... . Fh FOR DEPARTMENT USE ONLY 4' APPLICATION ACCEPTED BY DATE: AREA:_-7 q4.� ��o I; YANK,PIT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION BY DATE r (�p / F ADDITIONAL COMMENTS: .I ACCOUNTING ONLY: AID/ FAC# R el € PE CODE FEE INFO AMOUNT REMITTED C14ECKVEA3. RECEIVED BY DA7 89!PERMIT NUMBER INVOICE# .j