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PCIEATION FOR LIOUID WA I P,,'TlIk o'J0A0UIN COUNTY PUBLIC HEALTH SE � 1T7C0 StO`l ENVIRONMENTAL HEALTH DIVISION 'IRp\fTrv`�1)'- �y�ot�` RLitL�til�b,&A>E B,445 N.SAN JOAIIUIN ST.,STOCKTON,r,3,11 0 R{9Tr�t�� ITt figL?NS vI SPS1I� iI O?�1F' r � "�� '� 12091 46B-x420 4 L�1 y 3�y J liar{[ISIpv SES NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED d• Sb r T� 3� 1CampbI.in Trplicabl d 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 Public Health F; Services, Environmental Health Division. / 3 'L Job Address/or APN# 5/ w) J,""q ( City, < Lot Size Owner's Nammee /)-(_L,'ff!C zt,- I.ti{lu•/ Address j�gol ✓/ (1 .r^1 41-P Phone3331 J Cont rac tdrr1r LA ".2�-'{2Ct lffi-t'•AZ IIA Address•1 0,C?E-7L -7 Lic#�Z�Z'Z(�: Phone30'S Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIAODITION I 1 DESTRUCTION 11 PERC TEST(.)I I Haw many (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SE ER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) land U..Applice[ioa l Installation will serve: Residence_ Commercial_ Other_ Number of living units: Number of badr.—r : Number of employ...: _ Character of coil to a depth of 3 feet;i rr� r f PIt/Sump SolI Character: Water Table Depth. SEPTIC TANKIOREASE TRAP '�Ie Type/Mfg t / -L" C.P.clty /& c) No. Compartmented_ / i PNG TREATMENT PLANT [ ) Distance to nearest: Well () -f Foundation s Property line_ \/ LIFT STATION[] Size p Type of-Pune Sand Oil Separator (enclosed system) ,R LEACHING LINE No. 8 length of lines J -C''7[ Distance to Nearest: Weil IV 0/ Foundation 10, C[ Property Line FILTER BED /IT Width_ Length_Depth " " Well Foundation Property Line MOUNDED [J Width_Length_Depth " Well Foundation Property Line SEEPAGE PITS [1 Depth Size Number Well Foundation Property Line 6 —T I / � SUMPS Width Lengthlq�r Depth -C7 �eacL. m Well/QO Foundation /C7 Property Line SL DISPOSAL PONDS ❑ Width_Length I o Depth"`TT__ eft.- Well Foundation Property Line I hereby certify that 1 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 work for which this permit is issued, I shalL not employ any person in such a mamer as-4 to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the rt following: "1 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 \t.ell 24 haul\[a.lp advance for all required[nep.ctions. Complete drawing below. Signed% \�(\) .1 � Title: `'1 Date) �•' - T 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 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage disposal systems. 3. Dimensioned outlines and location of all existingand proposed 5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways,�,l� the property or adjoining property. and walks. W r A I N 9,. I I - PI BLIK FID LTH ER IC S' I O .:V , HE/IT NISI 3N n "x FOR DEPARTMENT USE ONLY Application Accepted by /! 1 ��" e� -Area: Z Tank, Pit or Sump Inspection by Date / / Final Inspection by _ r-Gc-a_.�late JS 9 Additional Comments: Agra cc. C ttiS a, wr - Ca "o,1uc14:6,._ ,..G. 6( w- ACCOUNTING ONLY: AID# FAC# Sh w 5=-� ,/[ PE CODE FEE INFO AMOUNT REMITTED CHECK CASH RECEIVED BY DATESR I PERMIT NUMBER INVOICE l ; ��