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4i t APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N.SAN JOAQUIN ST., STOCKTON,CA 95201-0388 (209) 468-3420 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplioatel PPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION JS MADE IN COMPLIANCE WITH SAN OAQUIN COUNTY DEVELOPMENT TIT/LE,CHAPTER 9-1 1 10.3�AND _THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. OB ADDRESS/OR APN# `'�� (""'��•� t�4'/� CCrFY /i�L�-E;�.�— LOT SIZE /Jj�<fL ADDRESS /,1'C If S7�LL�/� /cH�-Gi �//�� PHONE7//'�5�-34 SQL WNER'S NAME �is=-^>'//J!' �"�ti,,/l7'- // / / OMRACTOR •!� '„,ti LR l"=4-- ,7,r -ADDRESS �(- / �G"C/� L/✓ LIC# L=�C_.tC-C pHpNE %/�_7 UB CONTRACTOR ADDRESS LIC# PHONE YPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADOITION ❑ DESTRUCTION JO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) P6iC 7FST(sl I )HOW MANY Application# ISTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER❑ UMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES' HARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH EPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS KG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) :ACHING LINE ❑ NO.&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE LTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE IOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE EEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE JMPS ❑WIDTH LENGTH DEPTH D16TANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SPOSAL PONDS ❑WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 iEREBY 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 NO REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIESTHE FOLLOWING:'I CERTIFYTHAT INTHE PERFORMANCE OF THEWORK FORWHICH iIS 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 Q 1B-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 'ORKMAN'S COMPENSATION S OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. GNED X � � � TITLE: C7LVti C DATE: / 1 PLOT PLAN(DRAW TO SCALE(SCALE 'to NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 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. CI yj ( 1 ✓i/> S PAYMENT RECEIVED cplvlFL�l`Jh1_ 1 FOR DEPARTMENT USE ONLY 'PLICATION ACCEPTED BY C DATE: I AREA: C .NK.PIT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION BY DATE /2-F / r -DITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC# / PE CODE FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE SR/PERMIT NUMeI4 INVOICE 0 L•