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APPLICATION FOR LIQUID WASTE PERMIT ' n,,AN-JOAauiN COUNTY PUBLIC HEALTH SERVICL.-, ENVIRONMENTAL HEALTH DIVISION P.O. BOX 380, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.0388 {2091 468-3420 " NOWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complato in Tripikuto) APPLICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR 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 SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR A.Pm� .NNCITY . LOT SIZE OWNER'S NAME .,�1. OefT. K �:1.R'I.d�" ADDRESS : PHONEe �'' CONTRACTOR, r7e � �� ADDRESS �* ��'�'Cr�L'.s.A�� I -- UC#Ae# PHONEa SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION DESTRUCTION (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.] PE RCIEST(si[ I NOW MANY Applloetion# INSTALLATION WILL SERVE: RESIDENCRt COMMERCIAL© OTHER ❑ NUMBER OF LIVING UNITS: NUnnSIER OF BEDROOMS: NUMBER OF EMPLOYEES: :S CHARACTER OF SOIL TO A DEPTH OF iFEET: Pi"1'/SUMP SOIL CHARACTER: i .'- 'WATER TABLE DEPTH - SEPTIC TANKIGREASE TRAP 1 TYPElMFG t�C��dr�'.,i f/.% L,�.. CAPACIT'Y �:' tl + ... - _ -NO.COMPARTMENTS � .. ke PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE i 7- , 5 _ [A G UFT STATION 13 SIZE TYPE OF PUMP � AND OII�,SEPARATOR(ENCLOSED SYSTEM) J LFACHINUJUNE ;,r� NO.B LENGTH OF LINES ra�y'Cr`f� f 7 � DISTANCE TO NEAREST:-WELL /&6- FOUNDATION ! * PROPERTY LINE I^� FILTER IkED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE w a MOUNDED '❑I WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL p - FOUNDATION- PROPERTY LINE SEEPAGE NTS - DEPTH - r SIZE Z NUMBER DISTANCE TO NEAREST:WELL FOUNDATION 740'4' PROPERTY LINE �'ff"f SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE q<n DISPOSAL 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 F AND REGULATIONS OF NE SANJOAQUINCOUNTY.HOMEOWNERORLICENSEDAGENT'SSIGNATURECERTIFIESTHEFOLLOWING;"ICERTIFYTHATINTHEPERFORMANCEOFTHEWORKFORWHICH t THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CPQ_tFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I 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 X TITLE: —��- � ..,., DATE:-_�,r ./29" Cp°G - 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 DISPOSA4 SYSTEMS. 3. DIMENSIONED OUTLINES.AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, {{^^�� 6, 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. y - ... rte ,.. .. " t a ..st ... � f •o _ ei 1 I s tai "Y4 �Y x s.,. .. .... ....,: ..,, 1 � �-•,. rte- . w .... ..,.., FOR DEPARTMENT USE ONLY - s APPLICATION ACCEPTED BY a + ( r L ri r« N DATE: _ AREA TANK,PIT OR SUMP INSPE N BY PATE 1 1 FINAL INSPECTION BY/` r'i 'L'`"'l "`"'"" DATE J 1 ! ADDITIONAL COMMENTS: "'7ag,�,. " ,"';�r `'!..,,.r .l • L+'. (^ w' +w -G . :,/j ACCOUNTING ONLY: AIDX- FAC# ,` a PE CODE FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE Sit 1 PERMIT NUMBER INVOICE! �4fVA - �' cc) `- S