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APPLICATION FOR LIQUID WASTE PERMIT -.IN'JOAQUIN COUNTY PUBLIC HEALTH SERVICE..-' ENVIRONMENTAL HEALTH DIVISION P.D. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.03BO (209) 488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TFiplicata) 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 /.+9.11110.3�AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADDRESSIORA�PNA e;6 C?! CITY LOT LOTSI2E"�� OWNER'S NAME /�'/C''•J-7,1Y (',04v 7-t ADDRESS ii' PHONE .S" S' CC's: CONTRACTOR h�..•�__--_ _ _ _ADDREss��dD?�D�Z �1E�e��,r�ef uc# m!*30_--_ SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION MO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(:)T 1 HOW MANY Application# INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS:—/— NUMBER OF BEDROOMS:^ NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH 0 P SEPTIC TANKIGREASE TRAP ©TYPE/MFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP C SAND O}SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE Ar NO.d LENGTH OF LINER a� I-� DISTANCE TO NEAREST:WELL FOUNDATION_PROPERTY LINE X01. 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 DEPTH SIZE NUMBER'_DISTANCE TO NEAREST:WELL DO/ FOUNDATION C� PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE o- 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 OFTHE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE 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 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. K�1 SIGNED X TITLE: e, DATE; 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, 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. .` .. ., -.. 2. .-_. ... ...... :..... - - fes , .... .... - s � � . .. . 1 - , a - . roe �� .: - ... SArI 30r�t�(11 Ya �, -z� +f a .N� .. i lel w ,�i r- t F ):)100 iii7PJ 12(lf�#�1IrFJTA .:. .ENI) L N��l�. FOR DEPARTMENT USE ONLY - APPLICATION ACCEPTED BY - DATE: L+ AREA:Z [ Z TANK,PIT OR SUMP INSPECTION BY DATE 1 1 FINAL INSPECTION BY DATE A-7, k ADDITIONAL COMMENTS: DrCc-- Q �,- -�.y_,_ d #'1 ACCOUNTING ONLY: AID# FAC# Ia71l� PE CODE FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE SA I PERMIT NUMBER INVOICE 0 �Z c f 1� 0 �0