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(lUV*hR LIQUID WASTE PERMIT v' LIC111fth` C NTY PUBLIC HEALTH SERVICES „ki,ril l IR ENTAL HEALTH DIVISION 5 'I tVi��;"",• �, WEBER AVEl , STOCKTON, CA 95201-M •� �� {209) 408-3420 NOW-REFUNUABtE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED Momplatll In Triplicate} 1!IPPLIC ATION 16 HEREBY MADE ANC TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE AN "IN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNIN gOMPUTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. E WrTH S JUS ADDRESS/OR APN# �w Z 'L �✓ CITY_ -�' - y` LOT SIZ &L ' OWNER'S NAME_ Y�� PHONE - CONTRACTOA r'�(.i`z '" b-� � - �. � AUpRE6S�G-'( �L<..ot✓tC-7-�p �f"7` �""-- // ��jj SUB CONTRACTOR ADDRESS LIC# - P110NE a TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAR MADD{TION DESTRUCTION D IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.1 PERC TEAT{e1 1 ]liO,W MANY p Appilaalfan# INSTALLATION WILL SERVE: RESIDENCE OC COMMERCIAL OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROO __ 2.. NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: c--G � �-PIT/6UMP SOIL CHARACTER: .`J x 4-WATER TABLE DEPTH - SEPTIC TANK/GREASE TRAP Q TYPE/MFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT CI DISTANCE TO NEAREST: WELL - FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) I Cn ldS' e�1 LEACHING UNE M,Jf NO.6 LENGTH OF LINES — ��.� lF a-C..t.y-_. DISTANCE TO NEAREST:WELL,:FOUNDATIONf �PROPERTY LINE FILTER BED (�_ WIDTH LENGTH DEPTH DISTANCE TO NEAREBT;WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PtOPEPITY LINE SEEPAGE PITS ❑DEPTH SIZE - NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIiVE SUMPS WIDTHT��LENGTH_DEPTH Q DISTANCE TO NEAREST:WELL : r FOUNDATION - -�. ,.._ /�'k:'J � PROPERTY LINE-- DISPOSAL POND@ ( MOTH'. 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 4 AND REGULATIONS OF THE SAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH � TH19 PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN ACH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONT A TING GN R CE It THE FOLLOWING:"VC IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO I WORKMA 'S COMPE TION WB F C CALIF T CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION@. COMPLETE DRAWING BELOW. f /` SIGNED X ` ,�� TITLE/_- �� DATE:_ ��1� •'� . PLOT PLAN(DRAW TO SCALE)SCALE In '. 1,. NAMES OF STREETS OR ROADS NEAREST TO On 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, w 1 J "�4 4. -F44- . f .�. ;.. 1� rr 1 FOR DEPARTMENT USE ONLY APPiIC:ATION ACCEPTED BY -7 d DATE: AREA; TANK,PIT OR SUMP INSPECTION BY DATE ! M FINAL INSPECTION BY , DATE 7 .30 ! ! ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED dCHECKV ASH AECIMID BY DATE SA 1 PERMIT NW13M INVOICE if