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Q PPLICATION FOR LIOUIO WASTE PERMIT N'JMUIN COUNTY PUBLIC HEALTH SERVICEa ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 56201.0388 (209) 488.3420 WON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complatm In Triplimtb) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR 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 ADDRESSIOR APN# � _ / �L _ ,_CITY GLOT SIZE OWNER'S NAME � - �' JJ ADDRESS l� / ��/p/[� PHONE /T�� CONTRACTOR �//d• ADDRESS Viz-- •Tr-,rj0 rA LIC#�u• 7�� PHONE 060-eL y :�6> SUB CONTRACTOR ADDRESS —LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION I:3 REPAIRIADDITIVN'plk DESTRUCTION IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIP)I I NOW MANY Appiloa6on iR INSTALLATION WILL SERVE: RESIDENC� COMMERCIAL ❑ OTHER ❑ NUMBER OF WINO UNITS: NUMBER OF BEDROOMS:ff NUMBER OF EMPLOYEES:CHARACTER OF SOIL TO A ' LE DEPTH SEPTIC TANK/GREASE TRAP DEPTH OF 3 FE ��r?dre/�� 'PTTISUML`SO.IL CHCRA CE ITY �� WATER TABNO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OILf EPARATOR[ENCLOSED SYSTEM) LEACHING LINE � NO.I¢LENGTH OF LINES_ O ` .� �DISTANCE TO NEAREST:WELL FOUNDATION I >~ PROPERTY LINE FILTER BED ❑WIDTH LENGTHDEPTH' DISTANCE 70 NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION--�PROPERTY LINE SEEPAGE PITS DEPTH �`y SIZE NUMBER 2"- DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE�[e *' SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 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 AND REGULATIONS OF THE SAN JOAQUIN COUNTY.ROME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT INTHE PERFORMANCE OFTHEWORK 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:9 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 REOUIRED INSPECTIONS. COMPLETE DRAWING/BELOW. / SIGNED X TITLE: _ _ _ DATE: /�✓/ �:OI•f' PLOT PLAN(DRAW TO SCALE)SCALE "to F- 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. ., ..:.... ...:.... .. f. .,..:. - .. - ... . ...... .. . t,v :.;. ..,. ....... . .... ....... ... ... �... I .. .C� ... ... .. . . .. .... .....„..... .. .. „. . . .. . .. . . .. ..'... ..... ... - - .. � .. �.. FOR DEPARTMENT USE ONLY I cid APPLICATION ACCEPTED BYE DATE: 1laal + AREA: tI TANK,PIT OR SUMP INSPEC N BY DATE I I FINAL INSPECTION BY DATE I I I ADDITIONAL COMMENTS: I I ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE OR I PERMIT NUMBER INVOICE# 03`1 CA f bo %S