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APPLICATION FOR LIQUID WASTE PERMI SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOADUIN ST., STOCKTON, CA 96201.0388 (209) 468.3420 /� J� Jq3 ISD x-13 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complsts in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,7CHAPTER 9-1110.3 AND THE STANDARDS{OFF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# 344-7 4 / aVice-"i 5Ce 1� D CITY 5��Y�TDyv 3) AU&1 LOT SIZE 'Fejh-3K SP,b,cL-6 te5 DDa s loll D. N o�z>a+- yam_ -S�7, OWNER'S NAME `'' PHONE CONTRACTOR d V"N� ADDRESS UCN PHONE 6 SUB CONTRACTOR ADDRESS UC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEBT(a)I I HOW MANY Appeoadon# INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:.— NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH n SEPTIC TANKIGREASE TRAP ❑TYPE/MFG CAPACITY ( n G;"L. NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE br NO.&LENGTH OF LINES 3 X 60 r DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 36 D FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH ^ LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE MTS b DEPTH L-5( SIZE I 1 NUMBER_DISTANCE TO NEAREST:WELL FOUNDATION?PROPERTY LINE 300 SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1.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 RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FORWHICH 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 CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION& COMPLETE DRAWING BELOW. +7� sp--Q SIGNED X�•-- TITLE: ��rJ�I t I DATE: fit✓ ® ())) PLOT PLAN(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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAUCS. THE PROPERTY OR ADJOINING PROPERTY. (N 1 p FL 04 ro0 )— �I - L! EXISTI�s1 S Dila- 'N.i.' J i':l li 1 '; NEI!IC I IE/ 6E RVI( A aaTT'ID� � .JIR'fi�lfNl4� ' hf�� libi�� ._ 1 TA K iDo EX I"Tl L1 .'O' =-3 FOR DEPARTMENT USE ONLY j� '��'lJ APPLICATION ACCEPTED BY DATE: JAU '0 / A: I I I C-� ZL TANK,MT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY ;RAATE 1 ADDITIONAL COMMENTS: "S Ot '� G ( 1 ACCOUNTING ONLY: AID# FAC# I =1 PE CODE FEE INFO AMOUNT REMITTED CHEC ASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE# z21 oTS ��7°° w L 2a o See ooa7iS L4 Zile i �' 0°= .� ,� ,2ooa 7/sem