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p0 APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOADUIN ST., STOCKTON, CA 962010388 1209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Camplete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110./3 A/ /IJ /�AND THE STANDARDS nSOF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN. / O/ 8 a r h q% 4 R 11 N D (/U7 V MNC N CffMM CITY LOT OWNER'S NAME At Q UilLk ADDRESS i � efNrr?Hip gVIS FSRs NE CONTRACTOR TYIF)V T12 ADDRESS -/H UC1336 74 Rge, NE72 SUBCONTRACTOR ADDRESS +r LICA PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION 0 DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PIBUC SEWER IS AVAILABIF WRHIN 200 FEET OF BUILDING.) PERC TESTHI I 1 HOW MANY ' Apploeuon l INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER 6p O NUMBER OF IIVINO UNITS:_ NU.ISER GF BEDROOM/TS./: NUMBER OF EMPLOYEES: Imo,, CHARACTER OF SOIL TO A DEPTH OF 3 FEET: .dam PITMUMP SOIL CHARACTER: WATER TABLE DEPTH 1 SEPTIC TANKIOREASE TRAP ❑TYPE/MFG CAPA�CT' 2 ��CO4-1 L✓T U,COMPARFMEHT�b MO TREATMENT PANT❑ DISTANCE TO NEAREST: WELL V6J 1 c FOUNDATION 90 PROPERTY UNE —PF UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR)ENCLOSED SYSTEM) LEACHING UNE ,F 'NO.a LENGTH OF LINER .1 — /O LI/ DISTANCE TO NEAREST:WELL -FOUNDATIONI PROPERTY UNE �� L FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE FIT& I11 DEPTH SIZE NUMBER WELL_ DISTANCE TO NEAREST: NDATION PROPERTY LINE iUM yy WIDTH, TH� DEPTH DISTANCE TO NEAREST:WELL� - NDATION �PROPERTYUNE p� DISPOSAL PONDS •LJJ•MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PIgPERTY LINE��///"� ~ I HEREBY CERTIFY THAT I HAVE PARED THIS APPLICATION AND THAT THE WD WILL BE GONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE UW6,ANO RUlFS AND REGULATIONS OFTHESAN JOAQUIN COUNTY.HOME OWNERORLJCENSED AGENT'S SIGNATURE CERTIFIESTHEFOLLOWINO:'ICERTIFYTHATINTHE PERFORMANCE OFTHEWORKFORWHICH 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.- CONTMCTOR'S HIRING OR SUB-CONTRACTING 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 APPIICANT MUST CALL 24 HOURS IN ADVANCE FO//RALL IREQUIRED INSPECTION&. COMPLETE DRAWING BELOW. SIGNED%fMf /./( (/a-TMe-�� TITLE: L-Gv� DATE: I PLOT RAN(DRAW TO SCALE)SCALE_'le 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WANKS. THE PROPERTY OR ADJOINING PROPERTY. N c!' wI�� rftP 0 T2419'x' I w c T/}tji" A--T Lj�' tJ 1 2 (2o o bel S FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY C DATE: TANK.PT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION BY DATE 1 ADDITIONAL COMMENTS: r - 04 t ACCOUNTING ONLY: AID. FACP PE CODE FEEINFO AMOUNTREMITTED EC (CASH RECEIVED BY DATE SRLIPERMIT NUMBER INVOICE♦ C oa37