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PLICATION FOR LIQUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 3M EAST WEBER AVENUE, STOCKTON, CA SSMI X88 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F (CBmpIBts in Trolleals) n_--_ICATION 18 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 BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI ES.5NNARONMENT L HEALTH DIVISION. Ji AODRESSIOR APN# I I�-+ n LOT SIZE J-AR'S NAME ADDRESS "]' PHONE C CONTRACTOR ADDRESS / 1,J CONTRACTOR LIC#ADDRESS LICI L / r PHONE TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIMADDITION DESTRUCTION ❑ IN^EPTIC SYSTEM PERMr"tD If PUBLIC SEINER IH AVAILABLE MAIMN 200 FEET OF BUILOIN0.1 PLIC TE#TIo1 I 1 HOW MANY f! Appilgatlen/ INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ NEMER OF LIVING UNITB; tttt� NUMBEIR OF BEDROOM&: NUMBER OF EMPLOYEES; 1ACTER OF SOIL TO A--D--EEPPTH------OF G FEET: �+—FIT/SUMP SOIL CHARACTER: WATER TABLE DEPT" .iC TANKIORFASE TRAP ❑"',MFd_L.� _CAPACITY NO.COMPARTMENTS WO TREATMENT PLANT❑ DISTANCE TO NEAREST; WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP--- 7 `SAND OIL SEPARATOR{ENCLOSED SYSTEM? fL I .0„.ISNG UNE NO.4 LENGTH OF LINEB_Z �7. _ DISTANCE TO NEAREST:WELL FOUNDATION-pROPER7y LINE ILTER BED ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE .1n++NDEDr❑a�W-IDTH LENGTH `T DEPTH DISTANCE TO NEAREST:WELL FdUNDATION PROPERTY LINE_ iE u taE PITS OEpfH._ 612E- ,L NUMBER��DISTANCE TO NEAREST:WELL 0 FOUNDATION r, r PROPERTY LINE�.� IUMpi ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE (n� )ISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PIiOPE1TFY LINE Com] Hl :BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOROANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES 1 O REGULATIONS OF THE SAN JOAQUIN COUNTY,HOMEOWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:^I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FORWHICH HIS PERMIT IS ISSUED,f SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR WiL&ONTRACTING SIGNATURE CEIITIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORT(FOR WHICH THIS PERMrf IS ISSUED,1 SHALL EMPLOYPERSONS SUBJECT Vh .MAN'S COMPENSATION LAWS OF CALTHE APpLJCANT MUST CALL 24 HOURS IN IN ADVANCE FOR ALL RE4ULREO INSPECTIONS. COMPETE DRAWING BELOW. 7j— y Aroll SIGNED% . -_ ,. b.,17,1241-.-- ,._ TITLE: Cl DATE: PLAT PLAN fORAW TO SCALEI SCALE ^rq . ,MES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED !. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL BYBTEMB, I. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED BTRUC7URE8, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON `'-LUDINO COVERED AREAS SUCH A8 PATIOS,DFUVEWAYB,AND WALKS- THE PROPERTY OR ADJOINING PROPERTY. Ilk .... �k-A— 7....•+.-s—wry.. FOR DEPARTMENT USE ONLY -^� 4TLON ACCEf4ED BY _ r ,.,_..,..... .,,.� GATE: Z AREA: 1T OR SUMP INSPECTION BY PATE / 1 FINAL INSPECTION BY DATES NAL COMMENTS: Wff� rLQ r — f l 5 INTING ONLY: AID# FAC# )E FEE INFO AMOUNT REMITTED \ CHECK#/CASH RECEIVED BY DATE LIR/PERMIT NUMBM INVOICE I 10 z 7