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• APPLICATION FOR LIDUID WASTE PERMI 1 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVM <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 <br /> (209) 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin County for a permit to construct and/or install the work described. This application <br /> is made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmentalll Health Division. /� 'ice cc��nn�� <br /> Job Address/or APN# ZL{( o� <br /> .) � r - At2 yA-+k&Q 1 >�. ] d(i City Lot Size_ <br /> Owner's Name E"`. -lJ'1�ddress �E AJ .I �� <br /> G - G_J P1 0247 .74C130-X 47 'K_i Phone <br /> Contractor �L� �-�-�V'V'T Address�- f-' � fKtf VILG� 5,—tV0Y'"Lic1 Phone /y <br /> Sub Contractor Address Lic# Phone <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIOI(i4r REPAIRIADDITION I 1 DESTRUCTION I 1 PERC TEST(@)I I Now many <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> Land Use Application I <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living unite:_ Number of bedroom+:_ Number of employee: <br /> Character of soft to a depth of 3 foot: Pit/Sump Solt Character: Water Table Depth_ <br /> SEPTIC TANKIGREASE TRAP 11 Type/Mfg Capacity No. Compartments <br /> PRO TREATMENT PLANT I ] Distance to nearest: Well Foundation Property Line <br /> LIFT STATION[] Size_ Type of Pump­ Sand Oil Separator (enclosed system) <br /> LEACHING LINE H No. & length of lines Distance to Nearest: Well Foundation Property Lina <br /> FILTER RED ❑ Width_ Length_ Depth " " Well Foundation Property Line <br /> MOUNDED I) Width_ Length_ Depth " Well Foundation Property Line <br /> SEEPAGE PITS I] Depth_ Size Number_ Well Foundation Property Line <br /> SUMPS I] Width_ Length_ Depth " " Well Foundation Property Line <br /> DISPOSAL PONDS I] Width_ Length_ Depth Well__ Foundation Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances <br /> and State Laws, and Rules and Regulations of the San Joaquin County. Hone owner or licensed agent's signature certifies the following <br /> . "1 certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such a manner as <br /> to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the <br /> following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's <br /> conpensa of California." <br /> TM ap an <br /> so <br /> a Ito hours Inad anoe kr all utr pepeetbe. Complete drawing below. yn� <br /> Signed X Title: Date: <br /> 6�11P <br /> PLAN (Draw to Scale) Scale " to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline ofthe property, with dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> FOR DEPARTMENT USE ONLY _ <br /> Application Accepted bya <br /> y r I Dais:i* Area: ! <br /> Tank, Pit or Sump Inspection by Date / / Final Inspection by Date / / <br /> Additional Comments: c <br /> ACCOUNTING ONLY: AID# FAC# 71 v I 'C ' <br /> PE CODE FEE INFO AMOUNT REMITTED CHECK CAS RECEIVED BY I DATE SR 1 PERMIT NUMBER INVOICE 1 <br />