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APPLICATION FOR LIQUID WASTE PERMIT O p SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEr (Complete In Triplieatel Application Is hereby made to the San Joaquin County for a permit to construct andjor install the work described. This appticatic is made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Heatl Services, Environments( Health Division. Job Address/or APN# City_. 1/ Lot Size Owner's Name 14996 __Address Phone! , .. ((Contractor Address 224-16 18-153r Lic# O Phone Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION)( DESTRUCTION I I PERC TEST(s)I I HoMr o:anY _ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) (� Installation will serve: Residence Commercial. Other��15-]] (IS land Use Application 1' Number of Ilving unitss,I— Number of bedrooms: Number of e:rplayaea; 9 R� � haracter of soil to a depth of 3 fasts P SEPTIC TANKIOREARE TRAP [] T Yp°/Mfgit/sump Soli character: Water Tabls Depth_,Capacity No. Coma rtmenta-191-2 — KO TREATMENT PLANT [ ] Distance to nearest: Well Foundation Property line LIFT STATION[] Size Type af' Pump Send Olt Separator (enclosed system) ��LEACHING LINE 1K No. & length of lines - } Distance to Nearest: Well Foundation Property Line_ ,, —U� -- pe y ILTER BED [] Width Length Depth " 04 Well Foundation Property Line MOUNDED E1 Width Length Depth " " well Foundation Property Line SEEPAGE PITS J4 Depth Size" Number_ " " We(l-J-55L Foundation- )('0 Property Line` SUMPS U Width Length De th P well Foundation Property Line DISPOSAL PONDS i) Width Length Depth ° " Weli Foundation Property Line QV I'Ihereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinancds om_ and State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the fotlowing i 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 taws of California.,, Contractor's hiring or sub-contracting signature certifies the I following: "I certify that In the performance of the work for which this permit is issued, I shell employ persons subject to workman's compensation taws of California." The applicant must axil 24 he urs In advance for all required Inspections. Complete drawing below. Signed X Title• 6vat-/, Date:_�� PLOT PLAN (Draw to Scale) Scale " to �/ '�' 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewPAYM E tem or 2� Outline of-the property, with dimensions and North direction. proposed expansion of�ye► p�ggi�ystems. 31 Dimensioned outlines and location of all existing and proposed 5. Location of weds wit bbdd �i ft. on structures, including covered areas such as patios, driveways, the property or adjoir :�:�r�aT�t �l� and walks. !1 sf1l ILN CONIY F v i 4 OOFT 4 ` rp TY 71 i� IIT to 704r � FT- FOR DEPARTMENT USE ONLY pp ' t A l ication Accepted by - w Ta bat g—�- - - v0ate�. - - - A ea: 'nk P r Sump Inspection ate /;7 4(nal Inspection by T + . Date Additional Comments: �d ' �� ACCOUNTINO ONLY: AID# FAC# I i PE CODE FEE INFO AMOUNT REMITTED CHECKq6S!!2 RECEIVED BY DATE SRI PERMIT NUMBER INVOICE I i /17