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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 952010388 (209) 4883420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICemplsts in Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVILOPMENT TORE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRON ENTAL HEALTH DIVmION. JOB ADOm:seroR APNF� �JJ�(��, T�iq�707Gi/ fCA� clr�vF� /=��-[ LOT SIZE OWNER'S NAME fl-,"'AIA{'/ ADDRESS e -T el- /n1y��OGYJ_� L/�PHONE CONTRACTOR AnA�JC//C- ADDRESS ^G^^A�G��C//�phSII LICE PHONE SUBCONTRACTOR dry/ /"GL`�i!✓ ADDRESS ��Ci P/C✓ (JVZZK61/7 Ucf--f.5_ .1 MONE-561 � TYPE OF SEPTIC WORK: NEW INSTALLATION W REPNRIADIATION ❑ DESTRUCTION ❑ IRO SEPTIC SYSIEM PERMIITED If PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) P61C TEST411 1 HOW MANY APPEwtlon/ INSTALLATION WILL SERVE: RESIDENCE SI COMMERCIAL 11 OTHER ❑ 1� NUIRW OF UV NO UNITS:_ NUMBER OF BEDROOMS: NUMBER OF E/IPLO : CHARACTER OF SOIL TO A DEPTH Of3�,-FEET:OL4 PIT/BUMP SOIL CHARACTE 1 Q WATER TABLE DEPTH SEPTIC TANKIGRE,ASE TRAP q;r PEIMFO �/ CAPACT' ��G/7� NO.COMPARTMENTS "C P.O TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL 1S CK21�T— FOUNDATION e!; Fr RIDPERTY LINE 0/-�7 ` LIFT STATION❑ SDE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE � f f . - � .�r�TV�/� -PROPERTY UNE �fp FILTER SED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE U MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE EFEPAOE RTS ❑DEPTH SIZENUMBER DISTANCE TO NEAREST:WELL FOUNDATION—grx D EIR4ME' - EIIMpE PW1DTX1�/ LLNGTH .may DEPTH_ DISTANCE TO NEAREST:WELI.!U �FOUNOATIONa,,� PROPERTY UNE DISPOSAL PONDS ❑WROTH LENOTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE - I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFYTHAT IN THE PERFORMANCE OF THE WORE FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PESBUN IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING On SUR-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FDR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIIO/ONLL/AWS OF CALIFORNIA.- THE APPUCANT MUST CALL 24 LOURS IN ADVANCE FOR ALL REQUIRED..INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED% 7i��1.- TITLE: (iJfe�J/Y,Ni� DATE: �Cf /i /�7 PLOT PLAN(DRAW TO SCALE)SCALE •MP 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. E%PANEON OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,MVFWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPEIVY'. NCS.J r t� �I 1 ) 1 j/L v y 73`D lit" 199tl _ >/r Icf_IuII s�� .,I 141 I.a.li;F<. STAL.I =I V' f1i l!�r'p OR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY T \ - DATE, • T AREA: / T/ARK, TSR ZIP NSPECTION GYN V DATE V/ / FINAL INSPECTION BY DATE ^/ [7 / ADDFTIONAL CO ENTS:_ ACCOUNTING ONLY: Alp) FACS PE CODE FEE INFO AMOUNT REMITTED CHECI(I'ICASH RECEIVED BY DATE SR I PEIMITNUMBEI INVOKE0