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APPLICATION FOR LIQUID TE PERMIT SAN'JOAOUIN COUNTY PUBLIC tXALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 (209) 469-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complot#in Triplit#t#) 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 JOAQUIN COUNTY DEVELOPMENT TrTLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRON ENTAL HEALTH DIVISION, JOB ADDRESS/OR APNN I CITY LOT SIZE ! q OWNER'S NAME /�t -9D�DES�/ f� (., PHONE �J 17 119 44 CONTRACTOR _ADDRESS LIC# �/ ✓� PHONE %3 SUB CONTRACTOR ADORFSS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Cl DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WTHIN 200 FEET OF BUILDING.) PERC TESTI.)1 1 HGW MANY APpll..do # INSTALLATION WILL SERVE ENCEif' COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: '/ — NUM8SR 91 OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PT/SUMP SOIL CHARACTER' WATER TABLE DEPTH C C SEPTIC TANK/OREASE TRAP ❑TYPE/MFG 'I - CAPACITY I NO.COMPARTMENTS/�yy ✓ _ C PKO TREATMENT PLANT 1-1DISTANCETO NEAREST: WELL Q FOUNDATION PROPERTY LINE L/(,i UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM)/ LEACHINO UNE 11 NO.6 LENGTH OF LINES `�' DISTANCE TO NEAREST:WELL Ji/� FOUNDATION_PROPERTY LINE Z Q _ FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MO yI)ED ❑WIDTH LENGTH_DEPTH j DISTANCE TO NEAREST:WELL /., FOUNDATION PROPERTY UNE SEEPAGE PITS f/ ❑DEPTH SIZE NUMBER :/'.. DISTANCE TO NEAREST:WELL "/1 FOUNDATION /J PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OFTHE WORK FOR WHI� 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 SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S ✓ACOMPENSATION LAWSS 0 ORNIA'.' TyHEEAAPPUIUC A T MUST CALL 24 HOURS IN ADVANCE FOR (JAALLLLRR,EOURED INSPECTIONS. COMPLETE Y:71 ELOW. SIGNED% / / / �L" 9"Y� (L.✓t�� TITLE: `y /�7 PLOT PAN(DRAW TO SCALE)SCALE 'to1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISTEM OR PROPOSED 2. OUR LINE 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 VMHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 'op /7(oI < 1 � 1 \ �ar .I iP r 21997 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: q Iq AREA: AN ,I PIVOR SUMP INSPECTION BV DATE / / NAL INSPECTION BY �� DATE 1 1 DOITIOONNAL COMMENTS: L ACCUVNTINO ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED SY DATE 8A/PERMIT NU NIBER INVOICE# 0so 5 3 ala lrr� �71 � i