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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 386, 446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201.0388 (209)4083420 NO&REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 15$UED (Complete In Triplicate) Application is hereby made to the Son 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, Environmental Health Division. /I� Job Address/or APN# ay 3�-3 fl /�i(,a,a,;. �� City Lot Size Owner's Wane dflri-twirt -!�t_Y.0 d- 1•' d Address vnr< Phone •s contractor �'t-�+_. :✓;3S3f Address1 a7S rJ I :��cr']C�v�n Q\V .._Ltc# Phone Sub Contractor Address Lich Phone TYPE OF SEPTIC WORK: NEW INSTALLATION II REPAIRIADDITION y{ DESTRUCTION II PERC TESTb)II How many (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) land Use Application I Installation will serve: Residence_ Commercial. -,,/ other_ Nursber of living unites_ Number of bedrooms:_ Number of wWioyeear Character of Boll to a depth of 3 feet: CIA-'/ Pit/Sump Sall Character: ),Ja) Water Table Depth')O a r SEPT IOREABETRAP t] Type/Mfg ror��2Lr7-Z'-�/ M{-c capacity YgZC=o No. Comportmente_y�_ PKO TREATMENT PLANT [ ] Distance to nearest: Well Foundation Property line LIFT STATION[] Size_ Type of Pump Send OIL Separator (enclosed system) LEACHING LINE fid- No. 8 length of lines II T- DistancetoNearest: WeLt_)_SJL Foundation Property Lirw 2La/ FILTER BED [] Width Length Depth-S acf Well Foundation Property Line MOUNDED [] Width Length Depth "�'� Well Foundation Property Line iJ u SEEPAGE PITS J))' Depth .2�Size �M Nud>er__3_ (Well d , Foundationgp_ Property Line . r Z a .f avJ SUMPS [1 Width Length Depth " " Well oundation Property Line DISPOSAL PONDS I] Width length Depth " " Wall Foundation Property Line fi I hereby certify that I have prepared this application and that the work will ba 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 4. "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 sub-contracting signature certifies the following: 111 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 gall 24 hours Inedsfor■11 reyulrsd Impactions. Complete drawing below. Signed X rl� � Title: &,Dnee Date: y- 7- 3S- PLOT - 3SPLOT 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. ( acs n \ L— ol, YM y SH E I E 1'1E su 'cul ry \ NM NTA HE LTH I B- FOR DEPARTMENT USE ONLY Application Accepted by ,� '1�"N`Ir-[ia _ Date: 4S-' Area: �) Tank, Pit or Sump Inspection by Date / / Final Inspection by - Date Additional Coamsents: ,,.e --2o-,9 ( ---e/ ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AJAOUNT REMITTED F K/ ASH RECEIVED BY UATf SR I PERMIT NUMBER INVOICE IF / / 3 i�OtJ 6 5(�