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APPLICATION FOR LIQUID WASTE PERMIT �r SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-0388 G (209) 488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compkto in Tripliata) APPLICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED, THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SER ICES,ENVIRONMENTAL HEALTH DIVISION. !+ JOB ADDRESSIDR PN# o "--� CITY_- ` &33 LOT SIZE V/ f OWNER'S NAM r I (�` ADDRESS O� ! PHO E — f[ CONTRALTO w ADDRESS Pt O '1-7r LICI►3�PHONE�� 5 SUB CONTRACTOR -ADDRESS UC# PHONE TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAI ADDITION DESTRUCTION ❑ MO SEPTIC SYSTEM PERMITTE0,IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTts)I I HOW MANY Appnos8on# INSTALLATION WILL SEINE: RESIDENCEX COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UMTS:_ NUMB OF B 00 NUMBER OF EMPLOYEES; - CHARACTER OF SOIL TO A DEPTH OF 3 FE /SUMP SOIL CHARACTER: WATER TABLE DEPTH Q r SEPTIC TANKJOREASE TRAP ❑TYPFJMF6 CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST; WELL_ _ FOUNpATION PROPERTY LINE G f .'UFT STATION❑ SIZE TYPE OF PUMP SAND DIL SEPARATOR(ENCLOSED SYSTEM) a I LEACHING UNE ❑ NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE ^� FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH�T LENGTHr_DEPTH DISTANCE TO NEAREST:WELL _r FOUNDATION PROPERTY LINE ` SEEPAGE ATSDEPTH _SIZE �-NUMBER DISTANCE T4 NEAREST:WELL. r�FOUNDATION--AD.' PROPERTY LINE SUMPS ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UTNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION - PROPERTY UNE - 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 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 IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR K� 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 WORKMAN'StOMPENSATION LAWS CA ORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: DATE:/,3 T' PLOT PLAN(DRAW TO SCALE)SCALE "m • 1. NAMES OF STREETS O 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. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED.OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. i.. .., .... ., __..-. _. .,.., ... .. .. ..., - .., -- _ l .:. 5 E .. ...... . .>. . __ 1 .. . ...... _ . . . ...`..... 1 I RECEIVED A R 111 V5 �= SARI JQAQUINI LC3UC��Y� _ Aw . .. UBL C f� �1 f ;_ -; wtl5 r�las�..l'i l l"`'� I"IC-�11.I I , �.c ✓ _.. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEL]BY DATE: ARE ' jlr TANK, IT OR SUMP INSPEGTION BY DATE/7 NAL INSPECTION BY ' �� E I ADDITIONAL COMMENTS: r ACCOUNTING ONLY: AID# FAC# r PE CODE FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE OR 1 PERMIT NUMBER INVOICE# f