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APPLICATION FOR LIDUID WASTE PERMIT SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOADUIN ST., STOCKTON, CA 952010388 (209) 4083420 M (f-o110 NON REFUNDABLE PERMIT EXPIRES I YEAR FROM GATE ISSUED y (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 Title, Chapter 9-1110.3 and the Standards of Sen Joaquin County Public Health Services, Environmental x.Health-R Division. 1 a Job Address/or APR# 70 4 ( Q Av i,1 V e / City 41 c1 ell Lot Size Owner's Name V` �a Fb, 1e T- AddressV_ ' c� Olin 51 Coo r'� Phone -Zoz.) Contractor}ytrJ Y-h�1� PP r- ��TAddSAO ru(45- 1 o tido /N r1Y W Lic# 3$ ) Phone -Zo L) Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I PERC TESTIaI ) How many= (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Lard Use Applkation l Installation will serve: Residence_ Commercial_ Other_ Number of living unitar_ Number of bedrooms:_ Number of employees: Character of soil to a depth of 3 feet: P[t/Sump Solt Character: Water Table Depth_ SEPTIC TANKIGREASE TRAP 11 Type/Mfg Capeclty No. Compartments PRO TREATMENT PLANT [ 1 Distance to nearest: Well Foundation Property line LIFT STATION[] Size_ Type of Pup Sand Oil Separator (enclosed system) LEACHING LINE [] No. 8 length of lines Distance to Nearest: Well Foundation Property Line FILTER BED [1 Width_ Length_ Depth " " Well Foundation Property Line MOUNDED [1 Width Length_ Depth " " Well Foundation Property Line SEEPAGE PITS 11 Depth_ Size Number_ " Well Foundation Property Line SUMPS IT Width_ Length_ Depth " " Well Foundation Property Line DISPOSAL PONDS [1, 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 Sen Joaquin County Ordinances and State Laws, and Rules and Regulations of the San Joaquin County. Horne owner or licensed agent's signature certifies the following "I certify that in the performance of the work for which this permit is issued, 1 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 shell employ persons subject to workman's compensation laws of California." The applicant must call 24 hours In advance or all req red Inspections. Complete drawing below. Signed Title: An I "y Date: Y 1 -(iv : .1 PLOT PLAN Qtraw to Scale) Scale ) " to 00 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, orf structures, including covered areas such as patios, driveways, the property or adjoining property. and walks. n iAN OA UIN I,OUr TY BL11H TM � � 5t • f11• b w.ml S4 S ;kr fn:: (^ FOR DEPARTMENT USE ONLY /�--/�-��-rf�-,-�— Application Accepted by \ '� Date:_, , / Area:��} Tank, Pit or Sump Inspection by Date / / Final Inspection by `Date`! / Y Additional Comments: !. -< <, 11 -/�. f�_,' -{- +.=r..., G�e__C ACCOUNTING ONLY: AID# ` FAC# PE CODE FEE INFO AMOUNT REMITTED b1EC iICASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE / C ,h e C y -2- e�s� d