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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 962010388 12091 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT MD/OR INSTALL THE WOR(DESCRIBED, THIS APPLJCATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 A THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONM Al HEALTH DIVISION. f JOB AODRESSIOH APNI N2 l CT' i LOT SIZE OWNER'S NAME RESS kf PHONE CONTRACTOR --L— c DRESS 4:7— }W LICI RHONE SUBCONTRACTOR p0RE66 . 4 Ob��_L. PHONE TYPE OF SEPTIC WORK: NEW INSTAULATIONX REPAHUADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.1 PERC TESTM I I HOW MANY I W INSTALLATION WILL66RVE RESIDENCE❑ COMMERCIALJLI OTHER ❑ NUMBER OF RIVING UNITS:_ NUMBER OF BEDROOMS: NUIMIER OF EMPLOYEES; CHARACTER OF SpR TO A FIFTH OF 3 FEET. • PR/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TAFIK/CRFAfF TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENT WO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE r #Fp • UFT STATION❑ AIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM( R .Ei Gr`6, j� LEACMNO UNE C] W.&LENGTH OF UNES DISTANCE TO NEAREST:WELL FOUNDATION PEdYRTY lSmr) FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEARWELLEST: FOUNDATION PE JRN — q1� SLS MOUNDED ❑wIOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNOtLLYO n "d WA..• iaF �� L:. r;I_ _ 61%ENUTABEROISTANCE TO NEANEST:WELL EOII ''l0 `J.`q,L,,(y/INE•CI.t..` `� 9lM1Pb Ll vnplHLFNGTN DEPTH DISTANCE TO NEAREST:WELL—FOUNDATION �pROREnRY1l/II�IIOB''1,";:'. p�vl1 DISPOSAL PoNpi ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNOATON PROPERTY UNE HEREBY C!.RTR^I b.v, I HAW PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES O AND REGULP IIOr;C OF RIF ZAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY-THAT IN THE PERFORMANCE OF THEwom FOR"mH THIS PERMIT!S Ice 111),1 MALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU0,CONTRACI ING 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 COME'tMATIOH I MWS OF CALIFORNIA_' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION&. COMPLETE DRAWING BELOW. -9---P-- J '^ 1- / S SIGNEDX h r`�'1J TITLE I G-C-_�✓, LC l^ DATE: ` — 6 FY PLOT RAN(DRAW TO SCALE]SCALE •to O 1. NAMT,S DF SIHFE I I:L-K ROADS WARIEST TOOK BOUNDING THE PP.OPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPoSED 2. OUTLINE OF It - - --"'--' -••^••• ry FnTIDN — — EXPANSION OF SEWAGE DISPOSAL SYSTEMS. MM'N-1ON,11 INCLHOINp CWON � }u E/� 7aS9 2 nv-sEr aGIB'sric. aro OIL sa+A.. x J - 'w6o0sw Ft. sYsr EM ` DYA iN LAW _. S /V / asrQPAf,� tEa sFl. o� d 7 r:Ov ZELL I AZ PROPOSED BUILDIu NG A I PROPOSED BUILDING " A. vq vavc - - 90CY SHCR fN - r �L --_� 1 J —aAfru v:Ec. J, I-,?-4 FOR DEPARTMENT USE ONLY I C APKICATIUN ACCEPTED BY 1�'+'Y—fes GATE: L I J ggEq:� U 9 TANK,PIT OR SUMP INSPECTION BY ((jj ((�Y I'' DATE l I FINAL INSPECTION B DATE IIA-I CI ADDITIONAL COMMENTS: I Z S•I��J/OA -1 �•� L, �= j1.Lfec- -4- ( -- -5t" f z y? A,t. ACCOUNTING ONLY: AID# PACs PE CODE FEE INFO AM UHT REMITTED CNEC /CASH flEC_VED BY DATE M/PERMIT NUMBER INVOICE �tzz 5 15�• I u n� !1 S 0