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APPLICATION FOR LIQUID WASTE PERMIT SmN JOAQUIN COUNTY PUBLIC HEALTH ,"RVICES ` l -( ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION 18 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 SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/ ��•-�11 A;� CITYLOT 81ZE i OWNER'S NAME�J.�' •'/(/ .�f;,�� ADDRESS l,�Jyyl� / PHONE CONTRACTOR L��-.1 a:�� 1 i ADDRESS 111—:4-le LIC, �/S— ll-%S PHONE SUB CONTRACTOR ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI.)I 1 HOW MANY yy�, APPeweon If INSTALLATION WILL SERVE: RESIDENCE e4 COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 0 FEET: �, u^,c.� PIT/BUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ❑TYPE/MFG i'>(L CAPACITY 1700 NO.COMPARTMENTS PKO TREATMENT PUNT❑ DISTANCE TO NEAREST: WELL ZSC) t FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OFPUMP R --Ty SAND OIL fSSEPA�RATOR IENCLOSED 9YBTEMI LEACHING UNE CL3 NO.S LENGTH OF UNES r l wy� /&VAL" TANCE TO NEAREST:WELL Z5"01- FOUNDATION_PROPERTY UNE 1 S FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE �9 BLIMPS I�WIDTH _LENGTH )L> DEPTH 1 U DISTANCE TO NEAREST:WELL Z>U.- FOUNDATION, PROPERTY UNEP DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 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 BAN JOAQUIN COUNTY.HOMEOWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHK:H THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO � WORKMAN'S COMPENSATK)N LAWS OF CAUFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. .p O SIGNED X �C/' �� TITLE: DATE: PLOT PLAN(DRAW TO SCALE)SCALE_ 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. [6CANSIION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND P'ROw•— v "z_"`''-•'-�^-n 18 OF ONE HUNDRED FIFTY FT.ON Aes.ti M`(1wA1 eYeIf411. INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVE -�" �[)l r•,[1UIIf F , 1 O� 11 ll;11l IT11F:A1.1N D ISII N - _�_ 1 - d-� t l l llftONM� (C 11940 - - _ — 1 u�� t CRI. fi4)IRllc i - � Y7�� Tonto I - \\ I ti W wt�R IidE)A�.�\�• rr ,. ��I�i � �,�• IN IClow �QL�11If T II lnnwtlerhotod turn nromid c - • h 11 FOR DED ENT USE ONLY \ 1 APPLICATION ACCEPTED BV v ��L� DATE: A II DATE-5' / / AL INSPECTION BY (TANK,PIT OR INSPECTION BV ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID/ ^ FACO PE CODE FEE INFO AMOUNT REMIT D CHECK// ASH REC BY DATE SR/PERMIT NUMBER INVOICE Ar Pub.Health Serv.-Enviro.174(3/96)