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APPLICATION FOR LIQUID WASTE PERMIT *.iKN-JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) IS MADE IN COMMANCE_ THE JOADUIN HE WOW JOAQUIN(COUNTY DEVELOPMENIS HERESY MADET TIRE,CHCOUNTY TDESCRIBED. APTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY EA PUBLIC HLTH SERVICES,ENVIRONMENTAL HEALTH DMSIOH- WITH BAN JOB ADDRESS/ORAPN'+'I CCITY . �� LOT STI�TV- OWNER'S NAME n r/_FjvYn\G V .•�� ADDRESS .� - J -1a .'L� _PHONE CONTRACTOR (2��- � �0— ADDRE58 \ •S�✓ C'1`••'V L__ l"1��A--� LIOi1� PHONE 36$ ADDRESS 11Ci PHONE SUB CONTRACTOR fr�]11 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIMADNT)ON Ipl DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PB1C TESTI I I MOW MANT Application l INSTALLATION WILL SERVE: RESIDENCE E/yCOMMERCIAL 13 OTHER❑ NG BER Of OF EMPLOYEES:— CHARACTER OBER OF F SOILITO A DEPTH OF 3LfEE'T: `_' OMT: SUMP SOIL CNTARACTER:� �-'"`-d WATER TABU DEPTH SEPTIC TANKIGRE E TRAP ❑TYPERAFl3 CAPACITY NO.COMPARTMENTS Wo TREATMENT PLANT❑ DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM( E:,��, T LEACMNO UNE EL NO.A LENGTH OF LINES / OL LID DISTANCE TO NEAREST:WELL FOUNDATIONL PROPERTY LINE I(a� FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PRDPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE NTS BDEPTH SIZE NUMBERNUANCE TO NEAREST:WELL .S�FOUNDATION �DOI PROPERTY LINE /,to' SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 1 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.ROME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERT NY THAT 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 CAUF01W1A.' CONTRACTOR'S HIRING OR SUSCONTRACTING SIGNATURE CERTIFIES THE 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 lA OF pUTA.' TIyE APPLICANT MUST CALL 24 NOW IM ADVANCE FOR ALL MODIFIED INSPECTIONS. COMPLETE DRAWING BELOW. //1 /niI/// TITLE: #'-A '�✓1/i!`_ DATE: SIGNET X PLOT PLAN(DRAW TO SCALE)SCALE -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. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAU(S. THE PROPERTY OR ADJOINING PROPERTY. Y f a 61