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APPLICATOR LIQUID WASTE PERMIT SAN-JOAQUI TY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION y° P,O. BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 r+°01 (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 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTE /R 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN////-�.7 /-/n� -'I� �t7J% V y CRY .t �, LOT SIZE OWNER'S NAME !.,�.J�/ �� (�n JYYYS ��Al_/J PHONE CONTRACTOR M 1 y ADDRESS � Al L1C7 PgNEg'� SUB CONTRACTOR "TTT'/// ADDRESS IJC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDRION DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(.)I 1 NOW MANY ,�// AppSutbn INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER E 1 NUMBER OF LIVING UMTS: NUMRBI OF BEDROOMS: NUMBER OF EMPLOYEES: .._ CHARACTER OF SOIL TO A DEPTH Offp3r FEET: 'PIT UMP SOIL CHARACTER: /'� {� WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP KIP1RSFO (} CAPACITY f//('J /T�-trX� NO.COMPARTMENT.�j� PKO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE_Y� _ UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER RED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE S I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULER AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED 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 WOWLMAN'8 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING 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 REOUIREO INSFECTIONS. COMPETE DRAWING BELOW. SIGNED X L; _/1- [_ �Pt�2.(_/.S.�J� TITLE: DATE: wPLOT PUN(DRAW TO SCALE)SCALE 'to 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. 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 BLICH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. V N Z v ENVIRON -NTAL HF.A FOR DEPARTMENT USE ONLY (CATION ACCEPTED BY DATE: I/1 ✓ 7 AREA: c TAN PIT OR SUMP INSPECTION BY V DATE FINAL INSPECTION BY t^ V '1 DATE 1 7 l ADDITIONAL COMMENTS: A 11f ACCOUNTING ONLY- AID) ,FACE PE CODE FEE INFO AMOUNT REMITTED CHECK//CASH ITEC BVED BY DATE SRI/PflVA1T.-11. INVOICE!