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PPLICATION FOR LIQUID WASTE PERMIT i S COUNTY PUBLIC HEALTH SERVICES`:= ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 9520f-388 ., (209) 480.3420 NON-REFUNDABLE PERMIT EXPIRES1 YEAR F OAf DATE ISSUED FILA`' 4 APPLICATION i8 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONI STRUUCT ANDIORINSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPUANCE WTTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. � ADD JOB OWNER'S NAME APNN p{- / 3 Z n k CTFY_f� �� OWNER'S NAME _ !'TT�/. „_ADDRES71) S 1! ( ��r —LOT"Z Is CONTRACTOR r �' ADDRESS x /71]Z[ I�( � / y !I SONE UCF q0� PHONE SUB CONTRACTOR �� AOGRESS "�� ^ LIC# �PHONE TYPE OF SEPTIC WORK: NEW INSTALLATIO REPNRIADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF SUILOING.1 I PERC TFAT161 I I HOW MANY I APdiondon INSTALLATION WILL SERVE.- RESIDENCE❑ COMMERCIAL OTHER ❑ NUMBER OF UVINO UNITS: NUMBER OF BEDROOMS; NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: ~— PTTlSUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIORFJLSE TRAP ❑TYPEIMPG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST. WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.A LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERLY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL .. FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATIONT PROPERTY UNE DISPOSAL PONDS ❑WIDTk LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE i 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 CERTIFYTHAT 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 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM ATION LAWS OF CALIF NIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWINO�BEEjLOW. SIGNED X TITLE: /(. Z- DATE: PLOT RAN IDRAW TO SCALE)SCALE 'to 2. OUTLINE OF T1. NAMES OF HE PROPERTY,ETS OR DYTI-INLA �AND NOUNDRTH THE DIRECTION, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED TSV/ EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES ANINCLUDING COVERED AREAS U A TIOSARDN5VEWAYS,+ANPROPOSED LKS STRUCTURES, 6. LOCATION OF WELLS THE PROPERTY OR ADJWOININNGF RADIUS ONE HUNDRED FIFTY FT.ON AUG 7...20� - r7i ... . ... .. v\ SAN JOAoLJI�1 Ci�L1NTY �(� PUBLIC HEALTH SERVICES EhlWIfi01NMENTAL HEALTH QIVIS16N ,. PJ -S� x $L4 ... .. -.. . 'N' ........... ...... 4N GAGE . . . . . . ............ �'..� 4 . ...... ,� � 1 ....... ..... .......... ,,�`' �� hob LLEy &Ar € .. �..1x-.:� 'f.` .m%y ....t �.rw':'o+t I FOR pW TMFHT USE ONLY APPLICATION ACCEPTED BY -k4a a DATE: Ol / AR !`EA: TANK,PIT OR SUMP IINvvSPEee11C�TION BY DATE . I I FINAL INSPECTION BY - DATE�I A ITkI7A�CbMM-n — laec l J _ ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTEDCHEC ASH RECErmm BY DATE an I PERMIT NUMBER INVOICE#