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APPLICATION FOR LIQUID WASTE PERMIT `.SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,Z� ["1�Z -�� 2z � ( p �, v •Aub �� ENVIRONMENTAL HEALTH DIVISION BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 5 ��vs �,!- 3 r (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 Title, Chapter 9-1110.3 and the Standards of San Joaquin County PublicHealth Services, Environmental Health Division. Job Address/or APN>k rZi 1 3 W- ci F? City Lot Size Owner's Nelle Address T5-7(�. L i k�v (A i 2.ic Phone 4711-is ti Address Contractor 1LiNYlZrxt(7 t I►-�L Lica Phone` -13 r- Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIRIADDITIOM l I DESTRUCTION 1 I PERC TESTIe) How meal- (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEVER 1S AVAILABLE WITHIN 200 FEET OF BUILDING.) Load Use Application / Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms: Number of employees: Character of &oil to o depth of 3 foot: Pit/Sump Soll Character: Water Table Depth SEPTIC TANKIGREASE TRAP 11 Type/Mfg Capacity No. Compartments PKO TREATMENT PLANT [ ) Distance to nearest: Well Foundation Property line _ LIFT STATION[) Size Type of Pump Sand Oil Separator (enclosed system) LEACHING LINE H No. 8 length of lines Distance to Nearest: Well Foundation Property RRLine FILTER BED [l Width length Depth it " Well Foundation �RsRrl�ile MOUNDED [I Width Length Depth It " Well Foundation "AtV F3 SEEPAGE PITS p Depth Size Number " Well FoundationV,ARrrJef)y1Rf;� SUMPS Il Width Length Depth " Well Foundation �p"Ibtf, i 1 DISPOSAL PONDS H Width Length Depth " Well , Fotrtdatio�U�L)� L I�1 4LEtiv U — 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. Hone 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: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensation laws of California." The applicant oust call 24 lours N arvenw for s11 require✓ iospeations. Complete drawing below. S i fined X •n i 1'fz.-t' L�ZI Title: `�+�i-T- t•T((_7 .,Date: - PLOT PLAN (Draw to Scale) Scale 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. on structures, including covered areas such as patios, driveways, the property or adjoining property. and walks. z 1 4 ; r s ............