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?PPLICATION FOR LIQUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES I� ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-3N (209) 488.3420 a f MDIR•REFUKDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comptate in Triplicate) APPLICATION 09 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 BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Is JOB ADDRESSIOR APNN LOT SIZE OWNER' NAMECQ I -- •- _„`ADDRESS 'Sc,1C d�] PHONE i p•��y � CONTRACTOR_ ADDRESS —^ LICK PHONE SUBCONTRACTOR AODREBS II LIC• PHONE TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION pp ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF Bt11LDl .I PERC TEST(e)[ [HOW MANY :s Il APdioetlon 7 u INSTALLATION WILL SERVE: RESIDENCE 13 COMMERCIAL ❑ OTIIfR ❑ r MY VL./� NUMBER OF LIVING IJNlTS:�L HUMBER OF BEDRO M8: NUMBkR OF ANPLOVEES: IY CHARACTER OF SOIL TOA DEPTH OF 3 FEET: fQrj F4 YSUM /SOIL CHARACTER: WATER TABLE DEPTH - 04 SEPTIC TANKIGREASE TRAP '�TYPE/MF[)��'•t!yQ �4. CAPACITY___ �ATIO - u ,LI - NO.COMPARTMENTS._PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELLFOUNDN I'F10I'EfiTY LINE .S LIFTySTATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM- LFJICH[H6LINE NO.ti LENGTH OF LINER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BEO ❑WIDTH LENGTH DEPTH- DISTANCE TO NEAREST;WELL Ft)UNDATION PROPERTY UNEP —L1 MOUNDED} 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE. -Ul 'I SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS �� ❑WIDTH LENGTH DEPTH DISTANCE 70 NEAREST:WELL FOUNDATION PROPERTY UNE I DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION_PROPERTY UNE` l� �i � 1 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 REGUL:�TfONB OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'ICERTIFYTHAT IN THE PERFORMANCE OF THE WORK 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•CONTRACTINO SIGNATURE CERTIFIES THE FOLL NG: 'I CERTIFY THAT(N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNI THE APPUCA T MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIREO INSPECTIONS, COMPLETE DRAWING BELOW. ii _ SIGNED X .0 TITLE: a� i'IL 4-t ..,..„ DATE•. C� { I I PLOT PIAN(DRAW TO S(:ALEY SCALE I; t 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, J. 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. I 5e+( ... l R ..4- 199, J, : vie rAt ALT. N. 1b `- f ; _. I . 1 h - .. �''C* w �►raly�. . a 4 me_ . :; r .. . .. . % ... . .......... :.... .... s. . �.:a.� .. .: FOR DEPARTMENT USE ONLY �1 /Cl APPLICATION ACCEPTED BY s DATE: AREA:��_ TANK,PIT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION BY /) /1L�W!/W`��`� DATE 'r I I] 11 ADDITIONAL COMMENTS: �1 ACCOUNTING ONLY: AID# PAC j PE CODE AMOUNT REMITTED _NEC 1C ASH RECEIVER BY GATE 8R!PFRM17 NUMBEli INVOICE i � , r, <> 719 II . II