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1PPLICATION FOR LIQUID WASTE PERMIT SRu'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 38B, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 TITLf,CHAPTER 9-1110.3 ANO'T�E STANDA"SAN AQUIN COUNTY PUBLIC HEALTH SERV E� S,ENVIRON rAL HEALTH DIVISION. JOB ADDRESS/OR APtNN++ YZ CITY ^ �/ LOT SIZEr OWNER'S NAME ' AI�r /R- S'i►! °syL- A DRESS I �J,2(l �ij/ N%C�.�u/�.��/- mac., C-d/,�( PHONE 3Z 2- (7 C' CONTRACTOR ADDRESS b LIC# PHONE ' SUB CONTRACTOR " ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(*)I I HOW MANY Appllontion t INSTALLATION WILL SERVE: RESIDENCE Ike COMMERCIAL ❑ THER ❑ NUMBER OF LIVING UNITS:_ NUMBER OF B OOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL HARACTER: �WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG ' APACITY A// NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION �T PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) J -74 LEACHING LINE NO.&LENGTH OF LINES `��M_/ DISTANCE TO NEAREST:WELL FOUNDATION /(�y�/iJ PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑ DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SLIM PS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 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 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH 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: '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 ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED Xi J TITLE: C�W�N C. DATE: t� C' 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 PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. SIP Grq o _ d.. 0 0 ,9' �-6 PVl ov 6 dds 6 ocImo" p b l� has Y,o f- , all LL,q � Oxo MAY va . �. .. PUMIC IAF TH SERVICE' 12 ^ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y Ci �^L _ _ - DATE: AREA: �7? TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY / DATE 1-3 /`J� ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED HECK ASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE# Z' l l l,� ��1�� Lia- . �3! i9 = ^° !� 1- 030 5�