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APPLICATION FOR LIQUID WASTE PERMIT l ✓I4ylq((�� SAN JO! COUNTY PUBLIC HEALTH SERVICES Ero."NMENTAL HEALTH DIVISION U-Y) rep" P.D.BOX 388, 446 N. SAN JOAQUIN ST.,STOCKTON,CA 95201.0388 r _0 F 4 y ,�� (4� / (2091 488.3420 la� NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 u IComplds in Triplicatal Application is hereby made to the San Joaquin County for a permit to construct and/or install the work described. Thiapplication is made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Jaequin County Public Health s Services, Environmental Heaith Division. Job Address/or APN# 2061 F, h 3 ac 1F.TTT.F.17 9-4Bf) 74 G 7R City__�,Q]1] Lot Size 4] an - Owner's Name {e.�j Address_.j,_S Phone3AA-9G 3 Contractor Address 45Z8 FEATHER H IVERLic# ]4269 _ Phone47fi-nC11 Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORX: NEW INSTALLATION I I REPAIRIADDITION[I DESTRUCTION[I PERC TEST41 Ix flaw man;- 2 (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET Of BUILDING.) land Use Application l Installation will serve: Residence_ commercial_ Other_ Number of living units:_ Number of bedrooms;_ Number of employers: Character of sofa to a depth of 3 feet: Pit/Sill So$[ Character: I p Water Table Depth Y- SEPTIC TANKIOREASE TRAP ll Type/Mfg Capacfty No. Compartments C PKO TREATMENT PLANT [ ] Distance to nearest: well Foundation Property Line LIFT STATION[] Size_ Type of Pump Sand Oil Separator (enclosed system) I' LEACHING LINE LI No. & length of Lines Distance to Nearest: Wet[ Foundation Property Line FILTER BED [I Width Length Depth " Well foundation Property Line MOUNDED [I Width Length Depth Wet[ Foundation Property Line SEEPAGE PITS [] Depth Size Number " " WeLt Foundation Property Line - SUMPS [] Width Length Depth " " Well Foundation Property LineC DISPOSAL PONDS [I Width Length Depth " " Weil__ Foundation Property Line 1C 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. Hoare owner or licensed agent's signature certifies the following . "l certify that in the performance of the work for which this permit is issued, I shad not employ any person in such a manager 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, I shell emp}oy persons subject to workman's compensation laws of California." The applkanr must �call �2.4y9�hours in advance for ill required Inspections. Complete drawing below. ,��{ ,fit-; 7 y Signed X 'f�Nt Is��;l1• {. - rl: Title: -1J�{�',iNl�— Date: I"j,7-''IG) PLOT PLAN (Draw to Scale) Scale " to SEE ATTACHED SKEET 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 ex—i- -{-wage disposal systems. 3. Dimensioned outlines and location s --� -- -011 e„•��•...- - u o radius of 150 ft. on 3 property. M SHED r Wa1C.17I01 LINE(T)P) 3e3' 31 o' PARCEL 2 ouLZMA,1 R 31 *s i3 At. ]1 Hr MEN, RECEIVE JA14 4195 e ' ,aAN JOAQUiNi .'C0(,1'"1TY PARCEL 1 ra5LIL'I EEIu:Li l S21 VICES Ci: 'IiiONNIENITAL HEALTH DIVISION ,.ate 1/1 1/4 SECTION UNE Aqu1RONG ESTAIE�TI3. NH4V JAFW Et AL IE FOR DEPARTMENT USE ONLY Application Accepted by Date: - Area: i / t� Tank, Pit or Slurp Inspection by-7 Date__[ [e Final inspection by � �" Additional Comments; ! 5 ' ACCOUNTING ONLY: ASD# FAC# PE CODE FEE INFO AMOUNT REMITTED CHEC CASH RECEIVED BY DATE SRI PERMIT NUMBER INVOICE d' i �