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v _ 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 95201-0388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lComplets in Triplicatal 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 Services, Envirormental Health Division. )I-- '^ Job Address/or APNf{ �y 3 �3 /� �T7t^ f `� r City �{c.y{!�1'Z; Lot Size Owner's Name ,p}titan rc fig -t- Address (� Phone Contractor (IN-C- ��c��l1C Address -,/,l Lick 5 7<�I Phone_ LA33? Sub Contractor Address Licq Phone TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION bf DESTRUCTION 11 PERC TEST(sl I I How many (No SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Land Use Application Y Installation will serve: Residence Commercial_ Other Number of living unitsi Number of bedroom Number of employees: Character of soil to a depth of 3 feet: �`�F�Y Pit/Sump Soll Character: !'�r3 -� ) Water Table Depth ),-C, r SE `- _ No. Compertmenta UIec1t <�) PKG TREATMENT PLANT [ ) Distance to nearest: Well Foundation Property line LIFT STATION O Size Type of Pump Sand Oil Separator (enclosed system) LEACHING LINE f3 No. 8 length of lines //) .yD Distance to Nearest: Well Foundation�xr Property Lire: FILTER BED (] Width Length Depth orf /��' �L i Well Foundation Property Line MOUNDED [] Width Length Depth " " Well Foundation Property Line W it SEEPAGE PITS H' Depth .?S Size_ - Number _ " " Well Foundations_ Property Line ` Z �a<r SUMPS [] Width Length Depth " Well o c� oundation Property Line r DISPOSAL PONDS O Width Length Depth Well Foundation Property Line t 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 "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such a manner �- to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call 24//hours in adv nce for all required inspections. Complete drawing below- v Signed X Title: Date: PLOT PLAN (Draw to Scale) Scale " to 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 expansion of sewage disposal systems. 3. Dimensioned outlines and Location of all existing and proposed 5. Location of wells within radius of 150 ft, on structures, including covered areas such as patios, driveways, t e property or adjoining property. and walks. J ?'A j( a N l7' .fir E H iJl v 'OU, 1p