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, _.ro APPLICATION FOR LIQUID WASTE PERMIT � �o G SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX M%304 EAST WEBER AVENUE, STOCKTON, CA 9M`I-M (209) 468.3420 t 111011•REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complots in Tripliosts) R 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,CHAPTER 9-1 110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNN r CITY L1 cAe - LOT SIZE- OWNER'SSI NAME �,i')(i;"� `PPit�`Gt/)n ADDRESS CJ PHONE��1� f)+—Z'ZZ3 CONTRACTOR fQ�—A2 I 4 ADDRESS LICX PHONE SUBCONTRACTOR ADDRESS UCN PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADdT10N ❑ DESTRUCTION ❑ `,INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIS)I I HOW MANY Apptloodon# 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 IL CHARACTER: 'LOC ilgY'��_ WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP 'RTYPE/MFO CAPACITY lJ NO.COMPARTMENT PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELLC' FOUNDATION II PROPERTY LINE Cl LIFT STATION❑�S,IZZEE^ TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) / LEACHING LINE ILS NO,di LENGTH OF LINES � X S® DISTANCE TO NEAREST:WELL �FOUNDATION PROPERTY UN£ l J j FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE_NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS �'I AWIDTH�LENGTH 16 DEPTH_DISTANCE TO NEAREST:WELL=FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 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:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- 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,I 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. SIGNE TITLE: = DATE: I 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 1 A� INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. V� .. i. : a . _ ! . w .. .. . _ t\ . ...... . ...... .. .. ... _._ .. i�1 e .. ..... 1 d _ . "A Y N 41 .... W . I 199- Al! } .. !-. .. ,.._. I I�` a 1 1 _ ................... ... t, ..... ... .. .... FOR DEPARTMENT USE ONLY r C. APPLICATION ACCEPTED BY DATE: 6' AREA: 1 00 ' TANK,PIT OR SUMP INSPECTION BY s DATE / / FINAL INSPECTIONBY ( /.(/CN'K. t/�1 DATE ,. ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID/ FACN PE CODE FEE INFO AMOUNT REMITTED CHECK/CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE/ #'IS7I JAID 122;l 0 ,5- 03-)-800