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i APPLICA ION FOR LInuIO WASTE PERIL SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 Qr1M &=detiin (209) 468.3420NONREFUNDABLE PERIMIT EXPIRES I YEARFROIM DATE ISSUED (Complete in Triplicate) is hereby made to the San Joaquin County for a permit to construct and/or install. the work described. This application Count Pubtic Health t San Joa in Count Develo nt Title, Chapter 9 1110.3 and the Starxlards of San Joaqum ympliance with Joaquin Y i� Services, Environmental Health Division. �� Job Address I/or APN# City 1 lir:!/ Lot Size_ 7% Owner's Name Address Phone. Contractor S Address 1 nqa 1L/ j 8 +S L i r# Phone Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION I j REPAIRIADDITION DESTRUCTION 1 I PERC TESTtaI[1 Haw man;!. - (NO SEPTICiSYSTEM PERMITTED If PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) l5-)1 land Use ApplicatioR r Installation will serve: Residence Commercial Otherx-12�7";l ( IS 14-2 i) Number of )Luing unita:� Number of bedroomas Number of employees: haracter of molt to a depth of 3 feet: �Piitt/Sump Soil Character: Water Table Depth TP EPTICTANKIOREASETRAP [1 Type/Mfg d =- _/n�I/ _Capacity �l. lJ No. Compartments Z2 KO TREATMENT PLANT [ 1 Distance to nearest: Well . Foundation Property tine e LIFT STATION[] Size Type of Pump Sand Oil Separator. (enclosed system) LEACHING LINE IQ No. 8 length of lines s Distance to Nearest: Nelle' Foundation_a&L Property Line C Q' ___ f ILTER BED [1 Width Length Depth " If Well Foundation Property Line MOUNDED [] Width Length Depth " I' Well Fourxiation Property Line SEEPAGE PITS Depth_.9� Size_:JL!L Number_ It " Well DL Foundation CY3: Property Line l ~ SUMPS [1 Width Length Depth 14 'I Well Foundation Property Line E DISPOSAL PONDS ❑ width Length Depth Is of 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 Qv and State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the foltowing + : 141 certify that in the performance of the work for which 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, 1 shall employ persons subject to workman's compensation laws of California." The applicant must salt 24 lours In advance for all required Inspection*. Complete drawing below. l Signed X Title: /Jxw Date: PLOT PLAN (Draw to Scale) Scale " toi 1. Namesof streets or roads nearest to or bounding the property. 4. Location of house sewNBY tem or 2. Outline of.the property, with dimensions and North direction. proposed expansion of qq��e.Z�1j�1I�A� yatems• 3. Dimensioned outlines and location of all existing and proposed 5. location of wells witi (�rhllPod' i!f°'1YU ft. on structures, including covered areas such as patios, driveways., the property or edjoiryl��r"t%AQ and walks. s IN C[)UNTY Dl i0 J! S II F EL- FOR DEPARTMENT USE ONLY d Application Accepted by Date: Area: Z Tank, P 9r Sump Inspection by �_ Date.!Z- (_F4/naL inspection by t �� Date 7 c- �— 'AdditionaL Comments: _ ACCOUNTING ONLY. AID# FAC# PE CODE FEE INFO AMOUNT REMITTED CHECK ASH RECEIVED BY . DATE SRI PERMIT NUMBER INVOICE f 401 f. s r