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APPLICATION FOR LIQUID WASTE PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />�) P.O. BOX 300, 446 N. SAN JOAQUIN BT, STOCKTON, CA 962010300 <br />(2091468.3420 <br />1100 -REFUND Tf E S DATE ISSUED <br />Kemple& im TtiplinW <br />Application is hereby made to the San Joaquin County for apernit to construct and/or install the work described. This application <br />is wade In compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of Sen Joaquin Canty Public Health <br />Services. Envirormental Health Division. '- I <br />Job Addrosa/or APN# Y✓ City G Lot SizeC <br />Owner's Mane(.0,�'/ <br />_ ! & /'1. A�fireaa >� �. <br />Contractor Address Lic# Phone <br />Sub Contractor­4�/iC � AaL, :� Address�L�. !� �� /y/�4.YiT 4 Licr Phone <br />TYPE OF SEPTIC WORK: NEW INSTALLATHINX REPAIRIADDITION I I DESTRUCTION I I PEW TECTim) I�wuY <br />(NO SEPTIC SYSTEM PERPITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br />Land Use Applindom p <br />Installation will serve: Reaidencef,C Comrercial` Other_ <br />Number of living unites`_ Munber of bodrooart_ Number of employees: <br />Character of soil to a depth of 3 feet:P1t/bump Soil characters ¢-��dii�{, Water Table Depth <br />SEPTIC TAWJGREASE TRAP (1 typo/Mfg CapecitNo. caopartteents,a,_ <br />PK9 TREATMENT PLANT I Distan.e to nearest: Wel ll Foundation /4/ <br />- ,�T Property lino <br />UFT STATION(1 Size_ Type of Pump sand Oil Sepsrotor (anctosed system) <br />LEACHUIO UNE PC No. A length of lines 4/-4;17 "' Distance to Nearest: Wet Ie—� omd <br />aatJ-10ff Property 0-116r�j- <br />FILTER BED 11 Width Length__ Depth �� Wet I__Cfoudation>_ Property Line <br />MOUNDED 11 Width L"th__ Depth a Wall Foundation Property Lire_ <br />SEEPAGE PITS ❑ Depth Size Number Wall— ��--f-oundation �Property Line <br />SUMPS i/., Width Lengih_Zg";nepth-_� Weld_ Foudatian�Property Lina <br />DISPOSAL PONOS (1 width Length Depth m ■ Yell Foundation Property Line <br />I hereby certify that I 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 Regulation of the San Joaquin County. How« owner or licensed agent's signature certifies the fo(lowini9A <br />"I certify that in the performence of the work for which this permit is issued, I shall not employ any person in such a manner <br />to become subject to workman's compensation laws of L'alifornio.w CJntractor's hiring or sub- contract Ing signature certifies ih <br />following: ml certify that in the performance of the work for which thin parmit is issued, I shall mWtoy persons subject to workman' <br />compensation laws of California.11 <br />Tim appYceca asset call 24 Yours kr advance Mr all rsgnksd hwpos&am. Cn mplete drawing below. <br />Signed X AffTitle- aLy'yAt94r Data. <br />PLOT PLAN (Draw to Scale) Scale " to <br />I. Names of streets or roads nearest to or bonding the property. 4. Location of house sewage disposal *yet= or <br />2. Outline of the property, with dimensions and North direction. proposed expansion of sewge disposal systema. <br />3. Dimensioned outlines and location of all existing and proposed S. Location of wells within radius of 150 ft. on <br />structures, including covered areas such as patios, driveways, the property or adjoining property. <br />and walks_ <br />/% FOR DEPARTMENT USE ONLY <br />Application Accented by Cir }i r, . oats Are : 2 <br />Tork, Pit or Sump Inspectlon by Date / / Final Inspection by. _Dated' JgLLer <br />Additional Comments: <br />ACCOIINTIMO ONLY: AID# FAC# <br />IPE CODE FEE INFO AMOUNT REMITTED SN RECEIVED BY DATE BB I PERMIT NUMBER INVOICE # <br />4�pp b fi, 2ota <br />Y <br />