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.PPLICATION FOR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95MI-W (209) 468.3420 r ,� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplieete) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCATION 18 MADE IN COMPUANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNN V �. / �1,'✓//" J CITY � /'��-` �^' LOT SIZE " OWNER'S NAME • /s(�L�( DRESS I O� `"' 1 cp PHONZ?3-7f1"//911�V CONTRACTOR ADDRESS LICI PHONE SUB CONTRACTOR ADDRESS LICI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)I )HOW MANY / ` PPlloetlon I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER� Y j/!i/TNV! NUBER OF LING UNITE: NUMBER OF 9EDROOM6: NUMBER OF EM PLOYEFl: MVI CHARACTER OF SOIL TO A DEPTH OF I FEET: PIT/SUMP SOIL CHARACTER: �p WATER TABLE DEPTH ✓,~ GV / 'REAS VJXPE/MFO / CAPACITY /y V© NO.COMPARTMENTS PKO TREA .NT PLANT DISTANCE TO NEAREST: WELL 3fl FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYBTEMI LEACHING UNE ❑ NO. OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DISTANCE TO NEAREST:WELL FOUNDATIO RTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DI EARES FOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH SIZE NUMBER ANCE TO NEAREST:WE UNDATION PROPERTY UNE SUMPS ❑WIDTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑ LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIN v1 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 16 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,I SHALL EMPLOY PERSONS SUBJECT TO r. WORKM7c� TION LAWS OF J:::L:H�=ALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. {' SIGNED TITLE: f p DATE: -j PLOT PLAN(DRAW TO SCALE)SCALE I ue..c n�eTocrrc nw wn�D - I;EST m na wnurJnwr. RTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROp06E� �. ON �1:4- 7 ' V G I �_� !.-- i�J•Y I .�i �' (JLC I S ;`I f', �i.15 i/�c /�`J I.... 1 ' P IT ' MAY 2 1996 . r� I ' LTH SER Cl�7fvt6'i�T�L HEALTH Civ: IUPC; FOR DEPARTMENT USE ONL. APPLICATION ACCEPTED BY DATE: .M—<,Q AREA: "7 - & 0 , TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY 'bAT ry / ADDITIONAL COMMENTS:AC"l;W-40001AW ACCOUNTING ONLY: AID/ FACT PE CODE FEE INFO AMOUNT REMITTED HEC ASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE/ S 9j.-N o oa