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1 APPLICATION FOR LIQUID WASTE PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON. CA 96201.0388 <br />1209) 468.3420 <br />NON-REFUNDAILE PERMIT EXPIRES i YEAR FAOM PATE ISSUED <br />(Cmpiau Im Triplinta) <br />Appilcation is hereby made to the Son Joaquin County for a permit to construct and/or install the work described. This application <br />is made in compliance with Sen Joaquin County Devetopaent Tttla, Chapter 4-1110.3 and the Standards of Joaquin touray Public Health <br />Services, Environmental Health Division. r ` <br />� � <br />Job Addresslor APNfI Y Cit Lot Size <br />/� <br />Owner's Nasse L7,- <br />Address ' <br />_��yontractor Address / LicM`tFs✓ Ph <br />Sub Contractor Address Lich Phone <br />TYPE OF SEPTIC WORN: NEW INSTALLATION REPAIRIADDITION ( I DESTRUCTION ( l pERC TErrW (I Naw array <br />(NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 1S AVAILABLE WITHIN 200 FEET OF BUILDING.) <br />Land Use App;rafMa # <br />installation will serve: Residence V m <br />Coer Other <br />77 <br />Nusber of living unitvi� Number of bedrooms Naber of espioyeesl <br />Character of volt to a depth of 3 feetr t/Sump Soil C eracteri Water Table Depth <br />SEPTIC TANNiOREASE TRAP 11 Type/Nip *- Capacity lki o No. Compartments <br />PKI TREATMENT PLANT [ ] Distance to nearest: Wet Far:datfon ,lot Property line <br />LIFT STATION ❑Type of Pune Send oil Separetor (enclosed system) <br />LEACNINO LINE No. i (ength of line e Distance to Nearest: Wel l�!!t4-!!t4I Property Lirvi <br />FILTER RED 11 Width Length" Depth " is Welt- Foundation Property Line <br />MOUIIDED (1 Width_4� _ length Depth " " Well Foundation Property Line <br />SEEPAGE PITS Depth Si:e—UL Number " " Well& VF—Foundation roperty line <br />SUMPS lWidth Length Depth " Well Foundstian Property line <br />DISPOSAL PONDS (I Width Length Depth " " Well Foundation Property Line <br />1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances <br />and State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent'a signature certifies the following <br />: "I certify that in the performance of the work for which this permit is Issued, 1 shalt not employ any person in such a manner as <br />to become subject to workman's compensation law& of California." Contractor's hiring or sub -contracting signature certifies the <br />following: 01 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's <br />compensation law of California 11The %"Bust most 31 24 (wars ( aioa fat all repaired inWeetisse. Cokaplatc• drawing below. <br />Signed <br />T{tle:� Date•/ V -/J �-Sy <br />/ PLOT KLAN (Draw to Scale) Scale " to <br />1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br />2. outline of the property, with dimensions and North direction. proposed expansion of yetame <br />3. Dimensioned outlines and location of all existing and proposed 5. Location of walls wit 1 0 ft. an <br />structures, including covered areas such as ptios, drive ys, r the property or adjoi �1 <br />and walks. -,�2 ? my 1 a m4 <br />1^, 111 FOR DEPARTMENT USE ONLY r <br />Applicat n Acccpted by Date: re <br />Tank, Pit or Sump Inspection by <br />Additionat Comments: <br />ACCOUNTING ONLY: I AID# <br />Date / ! Final inspection <br />FAC# <br />PE CODE FEE INFO AMOUNT REMITTED CASH I RECEIVED BY I DATE SR PERMIT NUMBER <br />-L, Do I <br />;-r-6Rh eo�b <br />INVOICE 1 <br />