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cf:3 APPLICATION FOR LIQUID WASTE PERMIC �f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIUC 1 ENVIRONMENTAL HEALTH DIVISION /o # O P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA22k 8Q, (209) 468.3420 /� # C� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS Ed J,JV# (� (Complete in Triplicate) Application is hereby made to the San Joaquin County for a permit to construct and/or install the work descri is made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. c /I Job Address/or APN# �2�� w S 7l - Z t- , / w`/ L City lO,L Lot Size IF— Owner's Name LIE c" -I- i' t ��C 1`Address �(�c� I\I CA �, Int Phone Contractor Address Lic# Phone Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION(ll---REPAIRIADDITION I 1 DESTRUCTION I 1 PERC TEST(s)I)1 Now man; (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Land Use Application Y Installation will serve: Residence Commercial Other Number of living unites Number of bedrooms: Number of employees: Character of soil to a depth of 3 feet: `,Cl r"0 :U UCla it/Seip Soil Character: :41 /Eq 1Y4Water Table DepthX.� 0I SEPTIC TANKIOREASE TRAP ((�� (I Type/Mfg r- -2, e V\ Capacity -7©'✓O ;'I/No. Compartments PKG TREATMENT PLANT 01A Distance to nearest: Well r, Foundation-ll Propertyline , LIFT STATION[] Size Type of Pump Sand Oil Separator (enclosed system) LEACHING LINE [] No. & length of lines 3 /00 Distance to Nearest: Well 5 0 O f Foundatiork.Loo Property Lino f FILTER BED [I Width Length Depth " " Well Foundation Property Line MOUNDED 0 Width Length Depth It " Well Foundation Property Line + SEEPAGE PITS 0 Depth Size Number Well Foundation Property Line SUMPS [] Width Length Depth " Well Foundation Property Line DISPOSAL PONDS [] Width Length Depth " " Well Foundation Property Line I hereby certify that I have prepared this application and that the work will 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 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 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 compensat. f California." E The applicant must ea hours in a we r all required inepeetane. Complete drawing below. Signed X Title: ( Date: + 'I PLOT PLAN (Draw to Scale) Scale_" to Z-710 F- 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage disposal systems. 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways, the property or adjoining property. and walks. 4•b �� er n TJV7 r P if f U T° ALM 1 1934 DNikN'Ni i I AL iEAL +1 DI 001 J FOR DEPARTMENT USE ONLY Application Accepted by Date: !?,hlxArea: Tank, Pit or Sump Inspection by Date / / Final Inspection by — Date/Z// /1 y 04,11 Additional Comments: t'Q_c' a. _ S z+ a (cse� AC ACCOUNTING ONLY: AID# FAC# `lf e Cv� :u c-h�` w 1/6t vv ez2 c C', o- �c, PE CODE FEE INFO AMOUNT REMITTED HEC CASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE l