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APPLICATION FOR LIQUID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH S..8VICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESB/OR APN# / /tel/\�^-�� 1 �CS!C}�'//� Cm � �L�/-J�l LOT 81ZE-1m.;�j/G OWNER'S NAME /jam / /C) `�1 /LTJ/�f�.�!iC.�i� ADDRESS / 'f'�/'/ CS.�., k PHONE CONTRACTOR, J'C,,..ell y—, T��.�!^�:.•ic+/.':f.LfADDRES6_�n ? �1L^�i n.--� LIC, C /7_F140 HE SUB CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAJIVADDITIO N7777 DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEAC TEST(s)1 I HOW MANY Appllwtlon# INSTALLATION WILL SERVE: RESIDENC E,12(--COMMERCIAL ❑AA OTHER ❑ NUMBER OF LIVING UNITS:_ NUMBER OF B OOMS: 'L.�� NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: �'--� PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKJOREASE TRAP ❑TYMUFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION 13 SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE jiy NO.S LENGTH OF LINES / — DISTANCE TO NEAREST:WELL -Z. ,17 -' FOUNDATION 1 4 PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ,,LL❑��WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE ,cs SEEPAGE PITS -DEPTH SIZE T/ NUMBER DISTANCE TO NEAREST:WELL , J— FOUNDATION ��j PROPERTY UNE BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 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.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON M 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 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S:C0 TION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. �. SIGNED X TILE: DATE: c� PLOT PIAN(DRAW TO SCALE)SCALE_ -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. 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. ..... ....?.. .... ..:................................ .. .. .. ... rl ......... .. yi ... . . . ........:............;.. .,.. :............ . �", . : ....: : b .. .. .. .. ....,..............................:... ....... ; ...... ............. ...........:...... .. .. ....... .......... ,,of . ;. :......:........................ :..........: . ..... ..:.. ...:........ ................; . .....:.............:.............:..........................::.....: .. :........... All . .. ..:......:.. ..;... ..:.. ..;... .........:.. ......<.............<..........................;..... ..:......>.....:.. ..:. ......:.. ...:.. .. .. ..........:... .............. ......................:......................:.......:..............:.......... ............. ' P F¢F6. KIES l vlSf�h, _ :......:......<...............:............;......:.......... .............:......,. ...... .. .. .. Eql� .. ..... .... .. i :.FJ�l1IlFl(7N+AE+rITA t�ZII : :... ..:.....::.. ..: .....<... ..:..... .............................. ....... .... .. ...................... .. ......... ..:.. ..: .......:...........................:..............:......,. ......:.............. . ..... . .. ..:....... .. ..... ... .. ...>.... _...........;..............;.............:......:......:...... ......:.......:.....:.......:.......:......:......:.......:.......:...............:............ . . .:.....::.. ..: .:.......;.. ..:.. .. :......:.. .. ;.. ..:.... .... ..... ...;.. ...:.........>..... .. . :. . .... ..._ ..... .................. f�( '1A �y1 �/j��'FOR OFPBPIPAF,N�T USE ONLY ! /j "WU APPLICATION ACCEPTED BY I '�-'`-L •"'V1' v r` DATE: 1� G, AREA: /� 1 TANK, R SUMP INSPECTION BV DATE !C( / FINAL INSPECTION BY / " DATE`- / ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REM( TED HEC /CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE 0 y2l 1l� Jr Pub.Health Serv.-Enviro.174(3/96)