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APPLICATION FOR LIQUID WASTE PERMIT OC�C�c1 �l SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-0389 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete is Triplicate) 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 JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH )SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR AP/N# l 9 1� 1`� I(�I Vk J_ CITY L-o� ( LOT SIZE /IOD Pa OWNER'S NAME .p T r+}t2 r'T'1 /R ADDRESS C-2— PHONEpp `"r 0. )Z CONTRACTOR y}r<_ c ADDRESS -�rs1 S'�'CK_(C-{a.-� -61y� L1Cs 305-)� I PHONE 3 6 U -� F�j SUB CONTRACTOR ADDRE68 LICE PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAWJAD04TION DESTRLN:TION ❑ IND SEPTI;SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEO TESTIs1 T 1 HOW MANY AppUmdon f INSTALLATION WILL SERVE: RESIDENCE® COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF 6EDROOMS:—_ NUMSER OF EMPLOYEES: p / CHARACTER OF SOIL TO A DEPTH OF 3 FEET: )l PIT/SUMP SOIL CHARACTER: /Q 04t^'1 -SON11 WATER TABLE DEPTH 0 SEPTIC TANK/OREASE TRAP ❑TYPE/MFG 4c' k)e— CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAPJAT: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR[ENCLOSED SYSTEMI �� y LEACHING UNE 8 NO.S LENGTH OF LINES X D DISTANCE TO NEAREST:WELL AS-0 FOUNDATION—SV I PROPERTY LWIE__1[�D/ FILTER{ED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL / FOUNDATION PROPERTY UNE SEEPAGE ATS 9 DEPTH SIZE NUMBER_DISTANCE TO NEAREST:WELL,[ - FOUNDATION .�U/ PROPERTY LME 00 SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 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'$SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHCH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMA1ATION LAW$ F C FORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPBCTIONa. COMPLETE DRAWING BELOW. SIGNED X N'S COM $'\ TITLE: �'4—C- S CIT,�-- DATE: PLOT PLAN(DRAW TO SCALE)SCALE 'to- 1. o1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYMM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMa. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. 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. ........_... .......... ....;.. ...:............... ..:_..... :.. .. . . � ° \ V �\ t I - _ r ........ _. _ �� `� > J - - - - PAYMENT Q� MAR 211997 :