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I � i1 APPLICATION FOR LIQU10 WASTE PERMIT i SAN'JOA4UIN COUNTY PUBLIC HEALTH SERVICES' ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON CA 9LI'I0A (209) 488.3420 I ft NON-REFUNDABLE PERMIT EXPIRES 1 YEAR f DM DATE ISS ED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED..TIS PLIA E WITH H SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAP -rER S-1 1 10.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONME f JOB ADDRESSIOR AP477; - TL _; CITY Av' fj¢T SIZE OWNER'S NAMEr�G rI�S :r-4 15 q�'1 la _ ADDRESS - PHONE D__S � 141"�l�_ CONTRACTOR [ t\.—el ADDRESS LIC) PHONE SUBCONTRACTOR �. d AGGRESSQ {1 UCf PHONE .;6 TYPE OF SEPTIC WORK; NEW INSTALLATION�� REPAIRIADDITION D DESTRLK:TFON ❑ 4NO SEPTIC SYSTEM PERMITTED If PUBLIC SUMER IS-AVAILABLE-WITHIN 200 FEET OF BUILDING.) PERC TEST(*)1 1 HOW MANY 19f _I' Application f INSTALLATION WILL SERVE: RESIDENCE Y MMERCIAL ❑ OTHER ❑ r I�. NUMBER OF LIVING UNITS: L NUMBERI`OF BEDROOM$: 3 NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 F ; I� C.n PITISUMP SOIL CHARACTER: .SLrI�I WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP OF JG+-L Lt hcf-ef-e CAPACITY ,, 11 I — �d�.Z1T1 NO. PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI A LEACHING LINE IYNO.&LENGTH OF LINES fe-D' DISTANCE TO NEAREST:WELL l d D FOUNDATION {�PROPERTY LINE_ V FILTER RED ❑WIDTH- LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE Iy -- MOUNDED t©tt WIDTH .�yl.LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ' SEEPAGE PITS LJ DEPTH SIZE SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPSWIDTH yIy LENGTH _DEPTH_t�DISTANCE TO NEAREST:WELL-140: FOUNDATKIN��PROPERTY LINE DISPOSAL PONDS ❑WIDTH 'f.LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE O I C� ) I HEREBY 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 RULER AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CEFRTIFYTHAT INTHE PERFORMANCE OF THE WORK PORWHICH 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:'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE:.-- IJLt/K+t_r DATE• ! 1,•- i�.� '"1. ..y� PLOT PLAN(DRAW TO SCALE)SCALE 'to .'. - ---- 1 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 DIMENS10N8 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUGTUREB, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON tai INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. \� k , . cam. I .. W . _ . . �r . ..... �b � . . .. .. . . . . !` 4 .. � 1 ..... '1 ..,.. - t ... _. .- y _ .. .. ., ., .. .. -. .. .- : �f v Q '��.I IiJ t- ' - -� y, Lu �T n ..,.. - II FOR DEPARTMENT USE ONLY :0 �r 2 I APPLICATION ACCEPTED BY51 ,.`t DATE. - A; TANK,PIT OR SUMP INSPECTION BY �M DATEI. I FINAL INSPECTION DATE ADDITIONAL COMMENTS; IN ACCOUNTING ONLY: AIOX� PACS PE CODE INFO AMOUNT REMITTED CHECKf1CASH RECEIVED BY DATE SR 1 PERMIT NUMBER INVOICE f b� I`