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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 (209) 468-3420 NOM-REFUNDADIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN 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 SERVICES,ECVIRONMENTAL HEALTH DIVISION. JOB ADORE66/Ofl[AP-NIS /CITY (�7" —LOTSIZE L( I OWNER'S NAME T�',,�I-i\1� I—, e-r� ADDRESS l U 1�- L7-r�L�� Y� "'. PHONE CONTRACTOR D`-^'' ADDRESS 11CO PHONE SUB CONTRACTOR ADDRESS UCS PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAUVADDITION ❑ DESTRUCTION (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEINER IS AVAILABLE WITHIN 200 FkET OF BUILDING.1 PERC TEST(S(I 1 HOW MANY INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE__ _ MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE _ SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE C1-J I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCAT)ON 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 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH ) THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A6 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONT'RACTOR'S HIRING OR SUBCONTRACTING 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'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS. COMPLETE DRAWING BELO . SIGNED X LiWv,�"•�- TITLE: DATE: PL (DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR 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. DIMEN61ONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUD1140 COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. N . Ailh4T RIr CEIV JUN 51995 SAN J(iAQUll'l CVS P(JE]LIC HEALTH SERVI Iw ENVIRONME=NTAL HEALTH DIVISION `^ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY \- _ DATE: AREA: TANK,AT OR SUMP INSPECTION BY OATS / / FINAL INSPECTION BY DATE I ADDITIONAL COMMENTS: / �� ` ACCOUNTING ONLY: AID/ FACT PE CODE FEE INFO AMOUNT REMITTED CHECKS/CASH I RECEIVED BY DATE an/PERMIT NUMBER INVOICE f