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APPLICATION FOR LIQUID WASTE PERMIT SZN JOAQUIN COUNTY PUBLIC HEALTH �,—AVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 458-3420 SSE oq& 7 Al H",j NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��- 4"j—� )Colnpisb IB Triplieal�I APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUW COUNTY DEVELOPMENT TITLE.CHAPTER 9.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH JSER`VICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN�f y/A rI y 4f F/ - V"J V V L- � ,1l r 'f1 � crTY �.Ll D / LOOT SIZE y OWNER'S NAME �1r-11 L�.0 ` ADDRESS fK r PHONE -� •��/ CONTRACTOR V F1 f..f 5�AqC i1 ADDRESS -, 1 7-tt9lZA(k UC/ PHONE SUB CONTRACTOR ADDRESS UCf PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIAODiTION ❑ DESTRUCTION ❑ i (N0 SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTINI I JI HOW MANY ApPSasen! L-I / ` INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ _ 4,:--7 a2 [} NUMBER OF LIMING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PLT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIGRFASE TRAP ❑TYMWFG CAPACITY NO.COMPARTMENTS PK0 TREATMENT KANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR iENCLOSED SYSTFW LEACIONO UNE ❑ NO.A LENGTH OF UNES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED Cl WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDW ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE — SEEPAGE ATS ❑DEPTH SIZE NUMBER D16TANCE TO NEAREST:WELL FOUNDATION PROPERTY UTNE 1 SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE `Q 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 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMfT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR-S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFO(FOR WHICH THIS PERMIT I$ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO �- "WMAN'S COM ATION LAWS ALIFORNIA.' THE APPLICANT MUST CALL 34 HOURS IN ADVANCE FOR ALL REQUIRED INsPECTIONs. COMPLETE DRAWING BELOW. . SIGNED X_ 'L•L^C_ Trrm L1 l.LI�'l�F�-i4 _ DATE: T PLAN IDRAW TO SCALEI SCALE 'to — 1- I NAMES OF STREETS OR ROADS NEAREST TO OR BO LADING THE PMPEFITY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ^ 2. OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTUAE6. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXB. THE PROPERTY OR ADJOINING PROPERTY. ... .... .. _- . .. p. Y1 �7 .... i .. ... .. _ - .. V A >,,1.• .... .............. is RV, .... . .. .. -MAR 19.x$ 1 141 SPI I s i1fi -� .......... ....... -A r rI a �k.aalv:Siurd FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BV C DATE: AREA: . TANK,PIT OR SUMP INSPECTION 13V TE I I FINAL INSPECTION BY ��'�- DATE S I ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FACS PE COpE FEE INFO AMOUNT ROM i TED CHEC"ICASH RECEVED BY DATE SR I PERMIT NUMBER INVOICE S ro-s c_< N . Pub.Heafth Serv.-EnWiro.174(3196) r�