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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 (209) 468.3420 1110i-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATIF ISSUED (Complete in T►ipliaata) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION R.,Ll E WRH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 110,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH RVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNX 10qSQ HOY la + CiTI! — - � ^,w LOT SIZE OWNER'S NAME GLW� ADDRESS PHONE ^ V CONTRA-T, Ca' ADDRESS r UCN3asaa(0 PHON I0 SUB CONTRACTOR ADDRESS LIC* PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION D EPA) DDITION DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN o-FEET OF BUILDING.) PERC TESTIO 1 1 HOW MANY _ AppNostlon INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL CIOTHER❑ !• NUMBER OF LIVING UNITS: NUMBER O BE OMB: NUMBAI OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH 3 FEET: D�, 'PITISUMP SOIL CHARACTER: WATER TABLE DEPTH 'V V + SEPTIC TANKfORFASE TMP ❑TYPElMFIi CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE _ LIFT STATION❑ SIZZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LFACH INO UNE �NO.&LENGTH OF LINES — DISTANCE TO NEAREST:WELL5�D '4-FOUNDATION d•*PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE " MOUNDED ❑WIDTH_LENGTH_DEPTH DISTANCE TO NEAREST:WELL � FOUNDATION PROPERTY LINE SEEPAGE PITS IV DEPTH SIZE—NUMBER DISTANCE TO NEAREST:WELLlUC.�'F'.FOUNDATION Q PROPERTY LINE' BLIMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY TINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTYLINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORT(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 CERTIFYTHAT INTHE PERFORMANCE OF THE WORK FORWHICH 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 SUS-CONTRACTING 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 LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS„COMPLETE DRAWING BELOW, SIGNED TITLE: Vf� ��_OAT 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 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 FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY, :. t^ ....... ....... .i. .. ; ... L,.. ...... . _ - e ... ..... ... F;.. . <. ..... ... . to YEN. ........... . . . �!� - . 1Q.. .i..1 bdb' � A�l(�..3: .1:9. . PUB Lt jV Orf:}� r .. A�TE-� _ til-Fv�AL. w� FOR DEPARTMENT USE ONLY (Q]� APPLICATION ACCEPTED BY DATE: y r AREA: TANK,lsf OR SUMP INSPECTION BY ATE <NAL INSPECTION BY - ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FACX PE CODE FEE INFO AMOUNT REMITTED CHEC ASH RECEIVE]BY DATE SR!PERMIT NUMBER INVOICE# 0 �S