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APPLICATION FOR LIQUID WASTE PERMIT O�AN JOAQUIN COUNTY PUBLIC HEALTH SERVIt 110 ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9M`I-388 (209) 468.3420 ( f 73 ICON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED IColnplAtA in Triplicatel APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1 110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. , i . j p� JOB ADDRESSIOR APN#�� .: CIf'Y A0 - /l•r/71�(t LOT SIZE G�a � �p ADDRESS PHONE 4VJIJER'S NAME - ••'� �^ CONTRACTOR/J//y� �JAC -z L/UAA ADDRESS G. J 9 LIC(a��PHONE d� SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION ❑ I (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER k8 AVAILABLE WITHIN 200 FEET OF BUILDING.1 PERC TFATIsi I 1 NOW MANY � Applloetlee# INSTALLATION WILL SERVE: RESIDENCE 0 COMMERCIAL OTHER ❑ NUMBER OF LIVING UMT3:_5 NUMBER OF BEORoOMi:_ Nl1MBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 9 FEET: PIT/SUMP BOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIORFAAE TRAP IMFO �- CAPACffY_ M P1 - -NO.COMPARTMENTS PKp TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL -2* FOUNDATION_7 PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM( LEACYiNG LINE N0.a LENGTH OF LINES. , t ANCE TO NEAREST:WELL�I 71:' j� FOUNDATll �__3PROPERTY LINE„ FILTER BED ❑WIDTH LENGTHDEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED D WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER 019TANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFYTHAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAH 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:-1 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 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA," THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REDLORED INSPECTIONS. COMPLETE DRAWING/BELOW. SIGNED X 00( TITLE: ^�!"�+'?� DATE: --- 61, PLOT PLAN(DRAW TO SCALEI SCALE 'to 4. 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. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. 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 WALKS. THE PROPERTY OR ADJOINING PROPERTY. fl , JA :. � . .,- .... Irl -o- ...... �t -�......2....... ..�a ' a^ . - ct o - --�� - + ......... .. .. n...... (fit(.+4 � '.....- ...... .. .................. 4 � .:C a. :..w... .... S c. .':: : LIN 0-% b.:.c ....................---^� . :.. :.::::: FOR DEPARTMENT USE ONLY (//�,. lJ 1 1 YAREA; APPLICATION ACCEPTED BY_ V � �I�- DATE. r TANK,PIT OR SUMP INSPECTION BY' DATE I ! FINAL INSPECTION BY DATE G' I'd ADDITIONAL COMMENTS: R I1 c � t O ACCOUNTING ONL . AID# FAC# PECODE FEE INFO GLINT REMITTED CHECISIIICASH RECEIVED BY DATE SR!PERMIT NUMBER INVOICE# ?. 3p 5o F? j5n ooa''77