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_ APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH /�S/]ERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/ORA D -7 I CITY ( ( � LOT SIZE OWNER'S NAME ADDRESS PHONE 3�/7-/y-'!0_�V CONTRACTO ' ADDRESS L1CI�PHONECD` SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF PEPTIC WORK: NEW INSTALLATION ❑ EPA) DIT10N)57 DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEAC TESTI)I I HOW MANY AppEoatlon# INSTALLATION WILL SERVE: RESIDENC*COMMERCIAL OTHER 11 NUMBER OF LIVING UNITS: NUMBER OF BEDROO S: NUMBER OF EMPLOYEES: / CHARACTER OF SOIL TO A DEPTH OF 3 FEET: T/SUMP SOIL CHARACTER: �+ WATER TABLE DEPTH /v.� O SEPTIC TANK/OREASE TRAPTYPE/MFG / CAPACITY / � NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL /QQ 't FOUNDATION 4]' i'ROPERTY LINE, r f UFT STATION 11 SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE g NO.&LENGTH OF LINES 12—�=� DISTANCE TO NEAREST:WELL Of FOUNDATION �L� PROPERTY LINE � FILTER BED (❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑(WIDTH ,�ENGTHDEPTH DISTANCE TO NEAREST:WELL-----.,—FOUNDATION PROPERTY LINE__ rr SEEPAGE PITS Al DEPTH��61ZE _NUMBER_DISTANCE TO NEAREST:WELL.. ra t FOUNDATION 74 PROPERTY LINE SUMPS /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE - DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1� 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.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM SATION LAWS CALIFORNIA.' THE APPLICANT MUST CALL 24 HOAR&IN ADVANCE FOR ALL REQUIRED INS CTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: I DATE: PLOT PLAN IORAW TO SCALE)SCALE 'trr 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. EXPANSION 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,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. PAYMENT AUG 17 1995 SAN JOAQUiN PilBEIC HEALTH.SER VICES LNVfRONMENTA� �. HEAL.TH DIVISION i I v41 ... .:.... o . _.: . .... ............... L F-e--J'� APPLICATION ACCEPTED BY K T FOR DEPARTMENT USE ONLY DATE: AREA: V Z 1 / q s/ TANR SUMP INSPECTION BV DATE / C FINAL INSPECTION BY ADDITIONAL COMMENTS: r ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE HA/PERMIT NUMBER INVOICE t p3� I