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f I -APPLICATION FOR LIQUID WASTE PERMIT ' .1H'JOACIUIN COUNTY PUBLIC HEALTH SERVICIr ' ENVIRONMENTAL-HEALTH DIVISION tlr P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.0388 ' (209) 468.3420 NON-REFUNDABLE PERMIT E%PfRE3 ! YEAR FROM DATE ISSOED APPLICATIONIS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO COCNSTRIUCT IANDIORI•INSTALL TWITH S JOB QUINADD COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. HE WORK DESCRIBED. THIS APPLICATION I$MADE IN COMPLIANCE AN JOB ADDRESSlOR APN# '�� Crl' �� LOT SIZE OWNER'S NAME ADDRESS CONTRACTOR r, PHONE ADDRESS SUS CONTRACTOR LIC#Q22�PHONE ARpAE86 UCx PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPANVA017fTiON� DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) I Trio)[ i INSTALLATION WILL SERVE; RESIDENCaex OTHER NUMBER OF WINO UNITS: E COMMERCIAL❑ (3_�L NUMgpI OF BEDROOMS: 1-3 NUMBER OF L3WP'LOYEES: � 1 CHARACTER OF SO)L TO A DEPTH OF 3 FEET: PTflSUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANIUOREASE TRAP ❑TYPElMFO � CAPACITY No.COMPAWTMENTS PKG TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL k FOUNIATION_r[7 PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP _SAND OIL SEPARATOR(ENCLOSED SYSTEM) ' LEACHING LINE X NO,A LENGTH OF LINES / T DISTANCE TO NEAREST:WELLgUNDATION PROPERTY LINE FILTER BED 11 MOTH LENGTH DEPTH � bWANCE TO NEAREST:WELL FOUNDATION�Q� PERTY UNE LENGTH DEPTH TO NEAREST:WELL _ MOUNDED 11 WIDTH , f DISTANCE FOUNDATION SEEPAGE PITS 11 DEPTH PROPERTY LINE �E—�_NUMBER DISTANCE TO NEAREST:WELL � SUMPS � ❑WIDTH FOUNDATION PROI'ERTYUNE �. ^.LENGTH DEPTH DISTANCE TON "— DISPOSAL PONDS 13 WIDTH— NEAREST:WELL FOUNDATION PROPERTY LINE S LENGTH DEPTH DISTANCE TO NEAREST:WELL =� - FOUNDATION PROPERTY LINE r _ 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 v' AND IS PERMIT IS ISS ED,I SHALL NO EMUIN COY ANY HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIREBTHE FOLLOWING:'I CERTIFYTHAT INTHE I NANO SAN D ST T E LAWS,FORWI{ICH _ 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 C WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X s cl TITLE: ,(R, DATE: ✓7 r . PLOT PLAN MAAW TO SCALEI SCALE `to ^' 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 4• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3.'DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6EXPANSION. LOCATION OF SEWAGE DISPOSAL SYSTEMS, F WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR IND PROPERTY. ...... -- ...i.. ....,.. -- .. .. 771, .i.p � :.. U .. .. .. o . ..� .. I : ... _ .. { Iz> �` 1 ct. t . U e . ,. . n � � . � . ENT J A N 17 16195 ` a..� S�1{�l JCA �J4[�€t Jl iY I r�; ,. .. �. .... F✓lliLJ hf tTi �f7V�Ci L ��/ �. .. Yl { i;I E vTAI fit R"TN'D;+, TMENT USE ONLY y APPLICATION ACCEPTED BY DATE; AREA: ' TANK,PIT OR SUMP INSPECTION BY DATE---L— / FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY; AID# FACx PE CODE FEE INFO AMOUNT REMITTFD CHECK#1CASH RECEIVEb BY DATE 8R I PERMIT NUMBER INVOICE# i I