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APPLICATION FOR LIQUID WASTE PERNII.- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � �� COPY P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 9620'1-0388 112091 468-3420 )o( s lefj :bsv NON-REFUNDABLE PERMIT EXPIRES 4 YEAR FROM DATE ISSUED IComplats in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOlOR INSTALL THE WORKESCFUBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN OUNTY�P�U�BLLI�C*HERVICES,ENVIRONMENTAL HEALTH DIVIMON, A�� JOB ADURES610R APNO fD .�'��i .TY LOT 61ZE��t r7-ell-- OWNER'S NAME .I./LrI �/"l . io Y-L` If,", ADDRESS -5, <257"-/, �/J ' PHONE CONTRACTOR iG 13 Z-16JL�� Yf� /C�^ ADDRESS ��77� ��/ 7yr �'y-�li� UCR PHONE SUB CONTRACTOR ADDRESS L� /u 1 F• L./7 V+w +�. �LICY PHONE " TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAINADDITION ❑ DESTRUCTION ❑ {NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDINGJ PERC TESTWAN'NOW MANY Z APplloetlon 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: PITlSUMP SOIL CHARACTER; WATER TABLE DEPTH SEPTIC TANKlOREA&E TRAP 0 TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLO SED SYSTEM} '1 LEACHING LINE ❑ NO.i LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE AI FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 6LOA P4 ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ~ 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.HOMEOWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;•I CERTIFY THAT 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 f� SUB-CONTRACTING&GNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO V WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED IIN'SP,E-CTION$. COMPLETE DRAWING BELOW. SIGNED X� __ TkTLE:S-r+4F� �II. l1LI .DATE: PLOT PLAN RJRAW TO SCALE)SCALE 'm 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. `y 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,ORIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. l•r' ..-..... .............: ! - ............ . •r rn Z, D •�: rJ,,.P ..... .... ... .,.:_ ._ ., 1_ `. ...� (� ! �-..-•,.au>^•ra sec rn.. �,.a .................. Z r,a,w,M-ckw �` 2 J o IT i;3 •,\ �'�� \ ,I ` moi lL I` oda'' �2 t� O 1J r \ _ rrSAN J0AQl, ,Iv t✓JUIuI F PU80C HEALTH 6,� ENVIRONMENT �ri } AL h i�TH FGn vi*Aki NTr.N i U LOAM ---- APPLICATION ACCEPTED BY ild A DATE' AREA: TANK,PIT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION B - �"-�4 '�-""t�"�C7_DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIU# RAMI PE CODE FEE INFO AMOUNT REMITTED CHEC"ICASH RECEIVED BY DATE 48 I PERMIT NUMBER INVOICE P Z � 5go 3}7� 1.f� 7//V -7 tous rl �