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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 35201588 (209)468-3420 ((�� 7� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 T Pj1 (Complete iR Triplicate) 'PLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN IAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 1 IS ADDRESS/OR APN#R: ' �/'50 j(y'r�V� I (I(I/I I ll CfTY�(�� 1/�-1 LOT SIZE NNER'S NAME 43 1(��)11,^,�� 1P e 2 r,1+s) .¢I--ADDRESS i PHONE �✓ } )NTRACTOR V' L Il l�'C� \ �: 1 ADDRESS_ = J�l_J I,.( J C�F'T .h141 LIC(- PHONE 9 IB CONTRACTOR ADDRESS ^ l LIC/ PHONE 'PE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION LY✓ DESTRUCTION❑ 0 SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTpI I 1 HOW MANY AP 41-tlon J - 6TALLATION WILL SERVE: SIDENCE❑ COMMERCIAL L(]�OTHER❑ RARER OF LIVING UNITS: NUMHER OF BEDROOMS: NUMBER OF EMPLOYEES: IARACTER OF SOIL TOA D PTH OF 3 FEET: PIT/SUMP SOIL CHARACTER. WATER TABLE DEPTH �T PTIC TANK/GREASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS - O TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) ACHING LINE ❑ NO.6 LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE .TFA BED (DTH LENGTH DEPTH_DISTANCE TO NEAREST:WELL FOUNDATION / r PROPERTY LINE / i )UNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE EPAGE PTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SPObAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE EMERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ID REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WHICH IS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOIWMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIRING OR B- CONT CTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOPIO FOR WHICH THIS PERMIT IS ISSVEO,1 SHALL EMPLOY PERSONS SUBJECT TO )WOMAN' OMPENSAiION UW6 OF CALIFORNIA.')THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR/A/LLL BEWARED INSPECTIIIOON$. COMPLETE DRAWINO BELOW. iNED% TITLE: l/�17 .�iG.7o']� DATE:._ 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 O VTUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 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. .— -- —` ... J ' J G N FOR DEPARTMENT USE ONLY g ALJ/ AREA: _ 'LIGATION ACCEPTED SV DATE: (2 IK,WT OR SUMP INSPECT! BV DATE �i / / FINAL INSPECTION By DATE XTIONAL COMMENTS: / 30 p At,o %CCOUNTING ONLY: AID/ PE CODE FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE `�ZIS �Sv 2S0