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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX U% 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4883420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IGmpht$ in Triplk$t$I APPLICATION IB HEREBY MAGE TO THE SAN JOAOEAN COUNlTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR( DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE VJRH BAN JOAOVM COUNTY DEVELOPMENT TTIF, CHAPTER S-1110 .1 D THE STANDDAARDS OF SAN/J/OAQUIN COUNTY PUBLIC HEALTH SE CES, ENVMONMENTAL HEALTH DIV16N)H. ^ . / JOB ACC — W %l LU/v -J 9 �/ �/ ��9Q �— G Q lATg6fZE�-f+';�/UL OWNER'S NAME�l AA,*, � t IUVFQSAiAn YLt ^ppgElge rQj(�t.(Q � PHONE � 1 _A CONTRACTOR V \� �r' T C.... ADDRE86 pH S BUB CONTRACTOR ADOREUS LIC,F ICI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADOITIONDESTRUCTION ❑ IND SEPTIC SYSTEM PERN/TTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF SUILDINB.I Pott TFSTL.11 I NOW MANY App$eF$en I INSTALLATION WILL SERVE: RESIDENCE V COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNRS:_. / NU IBM OF SEDNOOMS: NUMBER OF EMKOYEU. CHARACTER OF SOIL TO A DEPTH OF 3 FEET• 4 PIT/SUMP SOIL CHARACTEFf � WATER T.. DEPTH /4!J SEPTIC TANKJORFJUE TRAP 13YPE T/MFO CAPACITY NO. COMPARTMENTSPL PRO TREATMENT ANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UHE LFT STATION ❑ SIZE TYPE OF PUMP // BAND OR SEPARATOR [ENCLOSED SYSTEMI LEACHING IMF NO. ♦ LEPIOTIF OF LINES /` Y-2� T/�,L�/>< DISTANCE TO NEAREST: WEU, � -/ FO N OATION�2 S ' PROPERTY UNE FILTER BTO ❑ WIDTH LENGTH OENH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE MOUNDED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ,�,I DEPTH SIZE NUMBER DISTANCE TO NEAREST: WELLh FOUNDATION'- ' ppppERFY UTIf � SUMPS ❑ WIDTH LFNOTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE DISPOSAL POND$ ❑ WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL 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 AOENr'8 SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE Of THE WOIIK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN H A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIPOFNIA," CONTRACTOR'S HIRNG OR SUBtOMiLAC SIGNATURE E8 THE FOLLOWING: 7 E IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TENS PEHMT 18 ISSUED, I SHALL EMPLOY PIERSONR SUBJECT TO WORKMAN' COM 10 WS F LIFORMA.• TIIF A NT MWT CALL 24 "CURB IN ADVANCE FOR ALL REQLAR IN$FE'CTION$. COMPLETE ORAW/EAB MOW. % SIGNED X TITLE: DATE: PLOT PLAN DRAW TO SCALE) SCALE ' We I. NAMES OF STREETS OR ROADS REST TO OR 80lNIDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PHOPOSEU 2. 0UTUNE OF THE PROPERTY, WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WTTKN RADIUS OF ONE HUNDRED FIFTY F.T. ON INCLUDING COVERED AREAB SUCH AS PATIOS, DRIVEWAYS. AND WALLS. THE PROPERTY OR AOJOINNNG PROPERTY. J s : 9y s P73. (JgUC II FOR DEPARTMENT UBE ONLY APPLICATION ACCEPTED B rI / DATE: � S � AREA: F(� TANK, T R SUMP NTS. TION BY DATE LJ AL IN8PECTON BV ATE ADORIO NAL COMMENTS. ACCOUNTING aNLY: A.1 IACD PE CODE FEE INFO AMOUNT REFA1TTFD CHECKIf ASH I RECHVEO RY DATE eR I PDRMIT NUMRFR INVOICE to