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APPLICATION FOR LIQUID WASTE PER,, 71 SAN JOAQUIN COUNTY PUBLIC HEALTH SER ._,S ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,445 N.SAN JOAQUIN ST, STOCKTON,CA 95201-0388 (209)466.3420 MGM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICorplets in Triplieata) Applicetim is hereby made to the Sen Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Devalopment Title, Chapter 9-1110.3 and the Standards of San Joaquin Canty Public Health Services, Environmental Health Division. Job Addressior APN* Qg(76 T�l�,/�,,w city Lot Size Owner's Name zp. /✓ Address sG _Phone Contractor, _Address J^40 41, PTir�e -� )g-)rte Lic# -!'-�•�IX — Phone?LE-S4a7 ey— Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITIONX DESTRUCTION I I PERC TESTIoI I 1 Now lase; (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) lard Use A0plliatlas Installation will serve: Residencs-40- commercial_ Othar°y_k,�;,;,(' 03 kehrvwo T iner of living unite Number of bedroanar_ Number of employaaBi :J haracter of soil to a depth of 3 feetlPlt/Sump Sall Character[ _ Water Table Depth EPTIC TANKIOREASE TRAP 11 Typo/Mfg—AA,. fin.✓ BqL capacity�4.�&2U No. Compertmenta�_ KO TREATMENT PLANT l ] Distance to nearest: Well - Foundation J Property line LIFT STATIONEI Size_ Type of Pump Send Oil Separator (enclosed system) LEACHING LINE 1Q No. & length of lines 9t-401 Distance to Nearest: We I t_g, L Fo.rdation G/l, Property Lim <12 ILTER REO [I Width Length__Depth " " well Fotandetion Property Line MOUNDED [] Width lengthDepth ,' s1 Weli Foundation Property Line SEEPAGE PITS f( Depth Size ZG Number iiellJ� Foundation 1M, Property Lira ea SUMPS 11 Width length Depth Well Foundation Property Line DISPOSAL PONDS L] Width length Depth " " Well Foundation Property Line O1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinentcds Qv and State Laws, and Rules and Regulations of the San �o uin County. Home.. owner or licensed agent's signature certifies the following d1 : "[ certify that in the performance of the work for which this permit is issued, I shall not employ any person in such a roamer as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." The eppBaat must mall 24 hears M advanom for oil required Inopectieas. Ccaplets drawing below. Signed Il �yr Title: 6at?x — Date: / PLOT PLAN (Draw to Scale; Scale " to vv CC 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewaAyM L�Nem or 2. outline of the property, with dimensions and North di,ection. proposed expansion of pM�a Z)p6 iitoms. 3. Dimensioned outlines and location of all existing and proposed 5. Location of walla wit Or-lR ft. on structures, including covered areas such as patios, driveways, the property or adJoi ry t n and walks. T�uJ rQLAN COUNTY So ! fid cS lC - I D411 10 w'14 y OInv"A FOR DEPARTMENT USE ONLY Application Accepted by n C'/ Date: : "AreaZ Z-- Tank, P r Sump Inspection by�/>�L' Ail Date LiffTnel Inspection by 4 Date (y Additional Comments: ACCOUNTING ONLY: AID# FAC# (FE CODE FEE INFO AMOUNT REMITTED CHECK ASH RECEIVED BY DATE SN I PERMIT NU INVOICE I Y /