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APPLICATION FOR LIQUID WASTE PERMIT Sm.4 JOAQUIN COUNTY PUBLIC HEALTH a"RVICES � ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Camplate In Triplicate) APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,/CHAPTER 9-11/10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENT/LL HEALTH DIVISION. JOB ADDRESS/OR APN#'/�1� S �.�a,le /e Lt1�G (4� 11j�, CrTV g ,aaF-L. LOT S12E_:3�� OWNER'S NAME _ - '/ �j �� ADDRESS 5 I.Im PHONE 0 CONTRACTOR /�/tea '!� l�i SP/.--r---fes—ADDRESS'.1 ZX C- 7 _ l7 - LIC/ Y5IV�.1r PHONE 3L•(I•-<o Z'l SUB CONTRACTOR ADDRESS LIC# 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 TESTIsl I I HOW MANY AppIlmdon# INSTALLATION WILL SERVE: RESIDENCE R COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UMTS:_ NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET:K _PIT/SUMP SOIL CHARACTER, km&x- WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY .. TrY NO.COMPARTMENTS PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELLr, '�' FOUNDATION PROPERTY LINE LIFT STATION❑UL TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING LINE UL NO.a LENGTH OF LINES: <0 Y DISTANCE TO NEAREST:WELL_FOUNDATION PROPERTY LINE �� ` FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS If WIDTH LENGTH 10. DEPTH IQ• DISTANCE TO NEAREST:WELLy}FOUNDATION, D. PROPERTY LINE 6 DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 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 SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR-8 HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: �.:.ev� y?i,sfi,y- _ DATE: PLOT PLAN(DRAW TO SCALE)SCALE_ 'to- 1. o1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED dao ExistimI RE Ln 6 1999s (E) 1200 U� FGaI.Septk t^ �� t71VTonk . I \ I ` \ ♦� \ \\� \�: \\X. � \\\: \..; \ \ ` I ff ♦� ' � 'f2rinrts l p•ISoK 1 IN X I I ? Hanxnerhead Turn around •J i ) FOR EPAPTMENT USE ONLY APPLICATION ACCEPTED By ^ c DATE: AREA:- TANK,ALT OR UM INSPECTION SV f�i�r DATE 9 FINAL INSPECTION BY DATE-fes ADDITIONALCOMMENTS:13 � y 6 ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMIITED CHECK# ST RECEIVED ILY DATESR/PERMIT NUMBER INVOICE# 1112 Pub.Health Serv.-Enviro.174(3/96)