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APPLICATION FOR LIQUID WASTE PERMIT �f�rjt SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE 1 ENVIRONMENTAL HEALTH DIVISION /-11D# O P.O.BOX 388,446 N. SAN JOAQUIN ST.,STOCKTON,CA 7,Ateh (209)488-3420 r /j MON-REFUNDABLE PERMU EXPIRES 1 YEAR FRO DA S E JV1/# Mmplsts In Triplicate) Application is hereby made to the San Joaquin County for a permit to construct and/or install the work descr is made in compliance with Sen Joaquin county Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. -n .� Job Address/or APNM ©O w City �C/C-11 - t_ Lot Size Owner's Name f a'�1� C \.{S 1�Jddrese o a Yt u Phone 7i</-7 ti Z contractor l� y�,R,� Address vy Lic# Phone Sub Contractor Address Lic/ Phone TYPE OF SEPTIC WORN: NEW INSTALLATION Y4—'~REPAIRIAOOITION i) DESTRUCTION I I PERC TESTisl tH Naw many I (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 2D0 FEET OF BUILDING.) Installation will serve: Reaidartce_ Commercial `�Other_ Lsnr Use Application Number of living unitsu_ Number of bedrooms: Number of employees: C7 Character of got to s depth of 3 fast;.t^411 250V t/Sump Soil Character: c� Water Tsbts Depth 11-5- C71 SLPTIOTANN)OREAaf TR�A)P/A� U Type/Mfg _li-,,o e' Ve Capacity -7000 oqa/No. Compartasnts PRG TREATMENT PIANTrvJT Distance to nearest: Wal I Foundation Property Line-.�' LIFT STATION❑ Size— Type of Pump Sand Oil Separator (enclosed system) LEACHING LINE 0 No. It Length of lines_a - /00 ! Distance to Nearest: Well 0 0 fi Fourdetlon.200 Property Linn f FILTER BED (I Width Langth Depth a Well Foudation Property Line MOUNDED U Width Length Depth Well Foundation Property Line—+ SEEPAGE PITS L1 Depth Size Number Well Foundation Property Line SUMPS [I Width Length Depth " '� Well Foudation Property Line DISPOSAL PONDS [) Width Length Depth " ° Well Foundation Property Line I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordirwm6sA and State Laws, and Rules and Regulations of the San Joaquin County. Hone owner or licensed agent's signature certifies the following . "1 certify that In the performance of the work for which this permit is issued, 1 shall not employ any person in such a asrmsr as to become subject to workman's compensation laws of California." Contractor'* hiring or sub-contracting signature certifies the-t following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa celifornia." The app d asst sa IsY1a In milvaComplete drawing below. �y -C Signed )< Title: Date: PLOT PLAN (Draw to Scale) Scale_" to -/(3,4 V 1. d f- 1. Names of streets or roads nearest to or bonding the property. 4. Location of house sewage die ➢ poral system or 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage disposal systems. 3. Dimensioned outlines and location of all existing and proposed S. Location of wells within radius of 150 ft. on structures, Including covered areas such as patios, driveways, the property or adjoining property. and walks. 2`C r- i-a r7 •'D s —toky–MENT R I�. D S AU 1 14 T `F N� t�I. N G.:UNT ME PAL 1EAt H OV ISiO n gj Q• FOR DEPARTMENT USE ONLY Application Accepted by Date.• Area: Tank, Pit or Sump Inspection by trate / L final Inspection by Date/L1 Additional Comments: -tfp fedczLJp�s•- 17-1 12 oQ` ACCOUNTING ONLY: Al DN FACA' PE CODE FEE INFO AMOUfNT.REMITTED HEC CASH RECEIVED BT DATE SR I PERMIT NUMBER INVOICE If �V lI-L4- '( .rr�� J �7 r y-Zzj