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APPLICATION FOR LIQUID WASTE PERMIT ' JAN'JOAQUIN COUNTY PUBLIC HEALTH SERVIL,, ENVIRONMENTAL HEALTH DIVISION BOX 388, 304 EAST WEBEFt AVENUE, STOCKTON, CA 9x201.988 (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROILMILEk ISSUEo icatel 'fJ��{' 1�� 12 f ^-/� APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT In ND/ORI INSTALL THE WORK DESCRIBED. THIS A�C�N i�A EINOOMpUANC�HSAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1110.3 AND THE STANDARDS OF BAH JOAQUIN COUNTY PUBLIC HEALTH SERVICED,ENVIRONMENTAL HEALTH 0III O JOB ADDRESS/OR APE/ / Q r A CITY a lf/C '� (A� LOT SIZE vJ OWNER'S NAME 2YE pbRE88 l v �� CONTRACTOPHONE RlG— ADDRESS_,/ /l PHONE SUB CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.) PEIRC TEST(s)I I NOW MANY Ap INSTALLATION WILL SERVE; RESIDENCE COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: ,- — NUMBER OF IMPLOYEFA, CHARACTER OF SOIL TO A DEPTH OF 3 FEET: W-2 PITISUMP SOIL CHARACTER: --e II.,'b � WATER TABLE DEPTH ! SEPTIC TANKlMEASE TRAP ❑TVPVMFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT 0 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ` LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR{ENCLOSED SYSTEM)` LEACHING LINE X NO.O LENGTH OF LINES /-T DISTANCE TO NEAREST:WELL,`FpUNpATH1N�j !PROPERTY LINE. FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑DEPTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE SEEPAGE PITS 11 DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE BLIMPS - 11 MOTH RJ:NS3TH DEPTH_�=DISTANCE TO NEAREST:WEL✓- FOUNDATION .3d F -nopERTY LINE,�j / f GT DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE ' I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SN 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 CERTIFYT14AT NTHE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON N SUCH A MANNER AS TO BECOME BUBJECT 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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: DATE- PLOT PLAN(DRAW TO SCALE)SCALE 'to ! 1. NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, f. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSION$AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ONE HUNDRED FIFTY FT,O ON Of WELLS WITHIN RADIUS OF O N � THE PROPERTY OR ADJOINING PROPERTY, � :,.. Az -, L--.. ...... e 0 .. .. � .. RECEI�E� . .. g 05 . . X00 ....... . . , . :... o SAN.JOA4UffV'CpUN7Y PUBI_iC HEALTH SI;f�VIGES . fdViRUNM�NTAll HEALrH QlVtSlOfy ,.r.... FOR DEPARTMENT UBE ONLY - APPLICATION ACCEPTED BY DATE: AREA: TANK,PIT OR SUMP INSPECTION BY DATE 1 I FINAL INSPECTION BY pAt �J , �y 7 ADDITIONAL COMMENTS: I h yR/ ACCOUNTING ONLY: AID/ FACE PE CODE FEE INFO -AMOUNT RFNIITTED CHEC /CASH RECEIVED BY DATE III SR 1 PERMIT NUMBER INVOICE 0