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ArrucAllUN I UH LIUUID WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOADUIN ST., STOCKTON, CA 952010388 (209) 468.3420 NON-REFUNOABIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplinto) -'PLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE MW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN )AQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. CITY ADDRESSOR AP1,1 . LOT WE NNEWB NAME � ADDRESS PHONE �)NTRACTOR T[ \M t3 S 't,7L) ADDRESS/e-+. 'T.r l(1 3�.. �f�'��V7 UCN - PHONE - SUB CONTRACTOR ADDRESS1I--�� LICE PHONE 'RE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRADDITION Ay DESTRUCTION Q • (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PENC TESTW 1 1 HOW MANY APPIIaeEon P STAUATION WILL SERVE: RESIDENCJli COMMERCIAL [3 OTHER ❑ 9 I•Iw1M8B1 OF LMNG UNITS: NUMBER OF nEDROOMH: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP/SOIL CNAIUCTER: J WATER TABLE DEPTH ITC TANIUGNEASE TRAPTYPEIMFG C't`JL�''Z' ,' A�-)I C,. CAPACITY 0 NO.COMPARTMENTS `G TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION SIZE TYPE OF PUMP ¢AND OIS.SEPARATOR(ENCLOSED SYSTEM) n -To-. —ACHING.-LINE ,--E9 NO.t LENGTH OF LINES s+•r"<-o _ DISTANCE TO NEAREST:WELL A--6 s FOUNDATION PROPERTY UNE �.TER am WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE WOUNDED ❑WROTH LENGTH DEPTH DISTANCETO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE RTS -0 DEPTH WE ']'i NUMBER DISTANCE TO NEAREST:WELL/&P/ FOUNDATION " � PROPERTY LINE RAPS - ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SMSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 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 ID REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:')CERTIFY THAT IN THE PERFORMANCE OF THE MW FOR WHICH IIS 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 '300 ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOO 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. r —SNEDX f$�IS ! lT` TITLE: t._-.� DATE: 11 vA I(' ROT PLAN(DRAW TO SCALE)SCALE 'to NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. _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. b� :L- I a Y w i J .,R r) bl - 'I tl