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f _ . PLICATION FOR LIQUID WASTE PERMIT SAk OAOUHY COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9MI-388 12091460-3420 NONREFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Gamplwte in Tripikato) a,, .-ICATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR 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 SERVICES,&NVIRIONMENT L HEALTH DIVISION. JADDRE6610R APNf ob CITY iti�l _ LOT SIZE A.;ER'S NAME �� -'�-� ADDRESS Z ' PHONE CONTRACTOR ADDRESS ! LICf�I��-! 7 if CONTRACTOR ADDRESS UC# PHONE P TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ IN^EPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESThI I 1 IIOW MANY h Appliaadon f INSTALLATION WILL SERVE: RESIDENCE n COMMERCIAL ❑ OTHER Cl NITER OF UVING UNITS; NUMBER OF BEDROOMS: -"2 _ NUMBER OF EMPLOYEES: Cl TACTER OF SOIL TO A DEPTH OF 3 FEET; -F�PITISUMP SOIL CHARACTER: WATER TABLE DEPTH EE..iC TANKIGREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT LE�HING UNE b-... SIZE TYPE 6 LEHOTH OF LINES F PUMP_T SAND OILSEPARATOR 4h 62 DISNCE O NEAREST:WELL'I `FOUNDATION_/_!L�PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE M[L+IiOED ❑�WH WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE_ BE WE PITS 1 .DEPTH SIZE _NUMBER_DISTANCE TO NEAREST:WELL0 FOUNDATION- r PROPERTY LINE ' SUMPS ❑mom LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDAMN PROPERTY LINE DISPOSAL PONDS ❑WIDTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 k H 'BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULER AND REGULATION S OF THE SAN JOAQUIN COUNTY.HOMEOWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOA WHICH V11 1`111S 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 SU'1-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO 'rV( :MAN'S COMPENSATION LAWS OF CALjiOTO'Tf THE APPUCANT MUST CALL 24 HOLMS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE ORAWINO BELOW. SIGNED X 'K�l TYLE: `I DATE: /,/ j— r PLOT PLAN IDRAW TO SCALE)SCALE 1. ,,MES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOBEp 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL GYBTEMB, J o I. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON I T—LUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WAUKS. THE PROPERTY OR ADJOINING PROPERTY. - - Z)A Z tl I ' 11 4 1 FOR DEPARTMENT USE ONLY ST ION ACCEPT EO BY, DATE: SAREA: 1T OR SUMP INSPECTION BY DATE ! ! FINAL INSPEC110N BY _ DATE 1-+L� 2—pr NAL COMMENTS: Wt!;I 7"�2 "Le /.0 a ce 1,'_lQ.. INTINO ONLY: Alb# FACN IE FEE INFO AMOUNT REMITTED \, CHECIK#!CASH RECEIVED BY OAT SA!POWIIT NUMBER INVOICE O Z 9