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APPLICATION FOR LIQUIYI WASTE PERNilt SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEI ENVIRONMENTAL HEALTH DIVISION f i-WD . P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON. CA 67�OQ�g111 (209) 460-3420 ?NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS E "f'b�.i lCemplets in Triplicate} —�- , Application is hereby made to the San Joaquin Count for q y permit to construct and/or install the work descri e lYts'�a�Tl is made in comironme a with San Joaquin County Development Title, Chapter 9-1910.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. ,/ Job Address/or APN# »Cj j ¢ _ $ _ �`�t� City__ C cl Lot Size Owner's Name._. -- �_ �Jlddress�=C,: ISI Cjz,: I, �� .�_' —....... _ Ilione.3�t i Contractor C> 1 �a 1�9.3� _Address Lic# Phone_ Sub Contractor - Address Lick _ Phone TYPE OF SEPTIC WORK. NEIN INSTALLATION 114-- REPAIRIADDITION I I DESTRUCTION I 1 PERO TESTIal III HOW MAR _ -- - (N4 SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) _ installation will serve: Residence Commercial 'f Other Lead Usti Application# � Number of living unite: Number of bedroom@: Number of enployeeo: � r Character of soiCto a depth of 3 foot: t<G 1'?d, Elrrflt/Sump Solt Character: L4 Water Table Depth�� SEPTIC TANI(jOREABE TRAP (] T e/Mf > yFti R Cepac L ty -�c No. Compartments - PHG TREATMENT PLAN'0140� Distance to nearest. WeIi Foundation Property tine� ^( LIFT STATION[] Size Type of' Pump Sand Oil Separator (enclosed system) _ LEACHING LINE I] No. & length of lines 3 /OCA ' Distance to Nearest: Well O 0 Foundatio .' a0 Property Line FILTER BED I] Width Length Depth " '+ Well Foundation Property Line MOUNDED (1 Width Length Depth Well foundation Property Line SEEPAGE PITS ❑ Depth Size Number " " Well Foundation Property Line SUMPS L] ' Width Length Depth ++ +' Well Foundation Property Line DISPOSAL PONTIS . (I Width Length Depth it Well Foundation Property Line 1 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. Hone owner or Licensed agent's signature certifies the following "I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such a manner as_ to become subject to workman's compensation laws of California.1' 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, 1 shall employ persons subject to workman's compense�t w&-Off California." Tiw applicant muat a@ -24 hours In vane r all required Inspections. Complete drawing below. Signed X_ Title: r [ C Date.• PLOT PLAN (Draw to Scale) Scale " to y i I. Names of streets or roads nearest to or bounding the property. G. Location of house sewage disposal system or 2. Outline of.the property, with dimensions and North direction. proposed expansion of sewage disposal systems. 3. Dimensioned outlines and location of all existing and proposed 5-. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways, the property or adjoining property. and walks. e ZZr i sP 4 k V MS E,T II !11 +'k ar"cc r A U 3 i 19 A e:31 C 06.4,c,5 F1,''t`a j(C _ FOR DEPARTMENT USE ONLY 4 Application Accepted by _ _ .�li_ T'+r-CSS.- .. _ Date: 6 ,t Area: _l Tank, Pit or Sump Inspection by Date [ / Final Inspection by Date��-/rr. /1 Additional Coments: rtea[:: r• . m .S ° 'L-+ _2 F !.2 `y�v pG� �.,•'"d'�j- SE-F.Y_Y�*+tk ACCOUNTING ONLY: AID# FAC# `.af 1 � PE CODE FEE INFO AMOUNT REMITTED CHEC ICASH RECEIVED NY DATE SR I PERMIT NUMBER INVOICE I /, �I' --a PLATE 17