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,✓y(�' 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 96201-0386 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED (Complain 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, Environmental Health Division. `r� 1, Job Address/or PN# �1rD,irI 2- ,,7� , y�r')I�'� C��. Ci ty�api ze � o p Owner's Hams ��L-L��Fp��7 N/ L�'✓��Y/• Address 112- 25p, Slr(�) ym(-.'�(J M. o�l Phone l3�l .F/701 Contractor DW�M Address Lic# Phone Sub Contractor Address Lich Phone TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION I I DESTRUCTION I I PERC TEST(m)11 Now many (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Land U"Application t Installation will serve: Residence_ Lomrerci al Other_ Number of living units,_ Nnnber of �?/ /l1/9-bedroanat Nuibar of employee$: 10 Character of moll to a depth of 3 feat: 1/U� Pit/Sump Solt Character: Water Table Depth SEPTIC TANKIGREASE TRAP II Type/Mfg EYL,71e5—Y-25 T Capacity 1', . k7io No. Coiq rtnrnte I� PRO TREATMENT PLANT [ 7 Distance to nearest: Well G Foundation Property line In LIFT STATION[] Size_ Type of Pure Sand Oil Separator (enclosed system) LEACHING LINE No. 8 length of lines X i 0c) /Distance to Nearest: Well- V^ Foundation 2�( Property Litw l¢JO FILTER BED 17 Width_ Length_ Depth " " Well Foundation Property Line MOUNDED (7 Width_ Length_ Depth " " Well Foundation Property Line f SEEPAGE PITS [] Depth_ Size Number_ " " Well Foundation Property Line SUMPS I] Width_ Length_ Depth Well Foundation Property Line DISPOSAL PONDS Q Width_ Length_ Depth " " Well Foundation Property Linz 1 hereby certify that I have prepared this application and that the work will be done in accordance with Sen 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 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 is issued, 1 shall employ persons subject to workmen's compensation laws of California." The applicant maluyt-p 124 he is in advance for all required Inspectbma. Complete drawing below. Signed X .0 Title: v- Date: PLOT PLAN (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 2. outline of the property, with dimensions and North direction. proposed expansion of sewage disposal systems. 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways, the property or adjoining property. P Y• and wal S. Or T LI! >' in FFV .- IF -1:1 y - 18 199.1 =H io. _ .'V'•i ..Jr�l ENT FOR DEPARTMENT USE ONLY Application Accepted by -f_ _� �� off'—Y— Date: Area: 42'df Tank, Pit or Sump Inspection by Date / / Final Inspection Date Additional Comments: 41a 6- ^''^-gyp )Q.�+-- i✓�- ,� q— SoV- ACCOUNTING ONLY: AID# FAC# PE CODE I FEE INFO AMOUNT REMITTED CHECK ASH) RECEIVED BY UATE SR I PERMIT NUMBER INVOICE /