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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 96201-0388 (2091469-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED N\ (Complete in Triplicate) Application is hereby made to the Sen Joaquin County for a permit to construct and/or instalL the work described. This application is made in compliance with San Joaquin County Devetopment Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. Job Address/or APN# 1"\. CI C\ /"//�� LV Cr'1V (' City (- l"C. eci Lot Size LL - bl. S Owner's Name V, r �a T-cw IP Y' Address (e+I`, rI Phone tf'/3 - 2c Z. I s Contractor +CS4�rV- lyd "C- 3V Pc ✓ �.6 Address yJ<�.� Ce,.-yi,gd /tv"rN t<C Lic# I'), 3;i 1 Phone jgJ -Zo Z.j Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I PERC TEST(s) Now man; Z- (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Land Use Application 7 installation will serve: Residence Commercial Other Number of living mI ts,_ Number of bedrooms:_ Number of employment Character of sell to a depth of 3 fact: Plt/Sump Solt character: Water Table Depth SEPTIC TANKIGREASE TRAP [] Type/Mfg Capacity No. Compartments Ii PKG TREATMENT PLANT I ] Distance to nearest: Well Foundation Property line LIFT STATION[) Size_ Type of' Pump Sand Oil Separator (enclosed system) i LEACHING LINE L] No. 8 length of lines Distance to Nearest: Well Foundation Property Line FILTER BED [] Width_ Length_ Depth Well Foundation Property Line MOUNDED ❑ Width_ Length_ Depth Well Foundation Property Line _J SEEPAGE PITS [] Depth Size Number_ Well Foundation Property Line I}— SUMPS [] Width_ Length Depth Well Foundation Property Line DISPOSAL PONDS I] Width_ Length_ Depth " " 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 U 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 work for which this permit is issued, I shall not employ any person in such a mamer as to become subject to workman's compensation taus 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, 1 shall employ persons subject to workman's compensation taus of California." The applicant must mail 24 home in advance(ot all req red Inspections. Complete drawing below. ' J Tom. Signed - )�)i- ,1. ti Title: t Date: - j -t ' L1 PLOT PLAN 4raw to Scale) Scale I " to O C (� 1. Nerves 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. Of mw'nsioned outlines and location of all existing and proposed 5. Location of welts within radius of 150 ft. on structures, including covered areas such as patios, driveways, the property or adjoining property. and walks. A M' e R �T- j-1b c .- , AN IDA UIN ...0 V020W ENI',.I HE l'iLl IVIS ON 0 U ,, st e -S O > Li; FOR DEPARTMENT USE ONLY Application Accepted by - Date:---c Area: Tank, Pit or Sump Inspection by Date / / Final Inspection by Date Y ` / Additional Comments: •. mac_� C //�e �2G //� tet% L21, //, �1.rB ,Ga v.«.r S-�m7' /c..t ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED NEC ICASH RECEIVED BY DATE SR 1 PERMIT NUMBER INVOICE# v c� ! 0