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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC }HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 2 � <br /> P.O. BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 96201.0389 <br /> {209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompiat6 in Tripirmto) <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUfN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110.3 AND THE STANDARDS O SAN JOAQUIN COUNTY PU C HEALTH SERVICES.ENVIRONMENTAL HEALTH MvisiON. 7 <br /> JOB ADDRESSOR APNNIO /V 7// /0- G/ (J �PQ1zGf/1GGV�/ CITY L-O� LOT SIZE 02[/A+a� <br /> OWNER'S NAME •/e- T�L�f-yI Lam. _ADDRESS � tJ.0- e �.n[ r , PHONE/T[ffl T <br /> CONTRACTOR �7. f G � j�, ADDRES6 rLr � �-I�IJt'7C_f�[�I� -�1�� LIC) 7 Z "PHONE / 5 3�3 <br /> SUBCONTRACTOR ADDRESS LIC# PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RFDAM/ADDI ON DESTRUCTION 13IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WfTHIN 200 FEET OF SUELD .) PEItC TIESTNI t 1 HOW MANY <br /> AppSeeflon# <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER❑ <br /> NUMBER OF WINO UNITS: NUMBER Of BEDROOMS: NUMBER OF EMPLOYEE&: <br /> CH _ E"SOIL TO A DEPTH OF 3 FEET: 6,a•C PRISUMP 801E CHARACTER. / lel WATER TABLE bEt'tN <br /> \ �n7 <br /> SEPTIC TAN EASE TRAP ❑TYPE/Mr-0 d{,L .�rL CAPACrry�L1_.`Y/ZP00 e7AL NO.COMPARTMENTS <br /> G311 ENT PLANT❑ DISTANCE TO NEAREST: WELLrElI"•7� 7+" FOUNDATION !L�r T-7 PROPEfrrY LINE / _'_ji- ` <br /> LIFT 6TATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) <br /> zt <br /> LEACHING LINE NO.S LENGTH OF LINES '/Cc+'Y�rT1C �DISTANCE TO NEAREST:N1ELLfOr)' FoUNDATPON--�PROPERTY LINE � I <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE <br /> MOUNDED. D WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> rr <br /> sEEPAOEPITS pEFTH SIZE NUMBER ti" <br /> DISTANCE TO NEAREST:WELL/ MrfFDUNDATIOHJ4j-0 _RiOPERTYLINE_S-__ � <br /> SUMP$ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE + <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST: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 AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OV EROR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OFTHE WORK FORWHtCH <br /> THIS PERMIT IS SUED,I SHA OY ANY PERSON 1 UCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR <br /> SUS-CONT TING GNATiI CERT IES E FOLLOWING: ) IFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMA 'e COM SATIpf•I F CAU UST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAIMNO BELOW. <br /> //� el/ [� Q!) <br /> BION` X TT11E: `CJT2-�`Y-o't DATE:---7 � ^!1T�",,.� <br /> PLOT PLAN(DRAW TO SCALEI SCALE "to <br /> 1. NAMES OF STREETS OR NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES S. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY PT.ON <br /> INCLUDING COVERED ARFAS SUCH AS PATIOS,DRIVEWAYS,AND VgUi*C . ,ft THE PROPERTY OR ADJOINING PROPERTY, <br /> ..,.. -. .,. .-.. -. - E <br /> :.. f�lCSC <br /> .w .. <br /> S.. .. .... .... .......... .. <br /> d. ..t { .... ht/. <br /> ...... <br /> _ k <br /> � <br /> ....;.. .:. .. :,.,. .,..... .,..:... .. <br /> � - <br /> + C <br /> .. wT <br /> I . , <br /> .. <br /> �. <br /> o <br /> rY, � <br /> ... �i <br /> . I-1 <br /> 2l <br /> a.max... gra a .� g9 <br /> €� , s� <br /> :..: :: � <br /> ! :,:....,,� <br /> :................ f5R�t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � • w^��•��'-+- -��OATE:_ !r -- ` �"~✓ <br /> 'I I� !! -���_���':�4J--' AREA: <br /> TA OR SUMP INSPECTION By <br /> /y '�/'� f DATE�f6NAL INSPECTION BY G�•O' DATE ✓r .� <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AID# FAC# r <br /> PECOPE AMOUNT REYJIITTED HEC (CASH• RECEIVED BY DATE SR 1 PEiIWIIT NUMBER INVOICE/ <br /> �-7z ` 4 l I a l'� �a 7a8 <br /> I go it/ PlAYMEN1 <br /> JUN 4 1996 <br /> SAN j(:,'�a{?I;IIv E.;iv(,,4� r <br /> PuBuic HEALTH SERVICES ! <br /> ENWRONMENTAL HEALtH DIVISION ,aI <br />