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XPPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SL,'ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 `f <br /> (209) 468-3420 <br /> NON-REFUNDABEE PERMIT EXPIRES I YEAR FROM BATE ISSUED <br /> (Complete In TrklkBtel <br /> APPLICATION le HEREBY MADE TO THE SAN JOAOUIN COUNTY FORA PERMIT TO CONSTRUCT AN MB INSTALL THE WOR(DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 O THE STANDARDS OF JOAQUIN COUNTY POBM HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> ��1T /✓pL Imo `/ 111`11 �.j�Ct, _ LOT BIZE_ <br /> JOB ADDRESBNR AM' L •�" `��j1v V Cm / `l _/� <br /> OWNER'S NAME •r 1 G-< L- r ✓V^E59 U GL ✓`L> 5/Y CIJIDEJ,P-L F.� Q �JTr ��•i/R10 HE <br /> �_ Me RHONE <br /> CONTRACTOR ADDRESS <br /> UCI PHONE <br /> SUB CONTRACTOR ADDRESS <br /> 1 11 <br /> TYPE OF INSTALLATION WORK: <br /> NEW INeTAITIOM ❑ REPAl11lAOdTIOM ❑ DFDTRUCn <br /> POIC TESTY(l 1 HOW MANY <br /> INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WOHIN 200 FEET OF BUILDING.) MPSoeEun e <br /> INSTALLATION WILL BONE RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF"NO UMTB:� <br /> NUMBER OF BEDROOMS: NUMBER OF OAPLOYEEJI: <br /> (YTIBUMP SOIL CNARACTERt WATER TABU DEPTH <br /> CHARACTEROF <br /> Of SOIL TO A DEPTH OF O PEFT: NO.COMPARTMENTS <br /> SEPTIC TANKJMA6E TRAP ❑TYPEJKRFG CMACNY <br /> MO TREATMENT MMT❑ DISTANCE TO MEMFJIT: WELL <br /> FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI <br /> DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> LEACRNO LINE ❑ NO.B LENGTH OF LINES FOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIOTII LENGTH DEPTH dETANCE TO NEAREST:LVELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL <br /> SEEPAGE M16 ❑DEPTH 812E NUMBER DISTANCE TO NEAREST:WELL <br /> FOUNDATION PROPERTY UNE <br /> WROTH LENGTH DEPTH❑ DISTANCE TO NEAREST:WELL <br /> FOUNDATION PROPERTY UNE <br /> SUMPS <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL <br /> FOUNDATION PROPERTY LINE <br /> 1 HERESY CERTIFY THAT I HAVE PREPARED TH19 APPLICATION AND THAT THE WVRK WILL BE DONE IN ACCORDANCE YRTH BAN JOAOUIN COUNTY ORDINANCES AND STATE AD AND RULES <br /> AND REOULATIONS OF THE SAA JOAOUIN COUNTY.HOME OWNER ORLICENBED AGENT'S SIGNATURE CERTIFIES THE MUD"NO:'1 CEIITIFV THAT IN THE PEIf01MAHCE OF THE WORK iORM/18C11 <br /> THIS KRTRACT SS ED,I" LL NOT F ES THE FOLLOWING.IN SUCCHHIA MANNER FY THAT IN THE PETO RM BALANCE OF THE WORK FUR WHICH HISME SUBJECT TO�RKMAWIT SPERMO'a(ISSUED.I BNALL EMPLOY PERSONS SUBJEATION LAW8 OF CALIFORIFIA.- CT TOO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-``THE APRICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPETE DRAWING BELOW. T <br /> SIGNED x <br /> �6i� , \-L)- TITLE: �') - C)l U-)op-. DATE 4� -�7 q• <br /> PLOT PAN(DRAW TO SCALE)SCALE— -to <br /> A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On MOMSED <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2, OUTLINE OF THE PROPERTY.WDM DIMENSIONS ANO NORTH DIRECTION. 6. LOCATION OF VEU8 WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND RLOPOSED STRUCTURES. THE PROPERTY OR ADJOINING PRGPEHTY. <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS <br /> IN <br /> fi�11��1`CNitENT ' <br /> SEP 8 <br /> h S.LNJii.EALTH SERVICES -.-.. <br /> CNVIRONMENTAL HEALTH DNISIDN <br /> GF DEPARTMENT USE ONLY A E� <br /> [ ( DATE: 1 — Y 'HTE o <br /> APRJCATION ACCEPTED BY OR BUMP INSPECTION OV Y / j O/ �� <br /> TANK,PN DATE / I FINAL INSPECTION BY IJ t ` DATE <br /> L <br /> ADDITIONAL COMMENT 6: <br /> •- �TYW��v. � <br /> Aecovnn90 ONLY: <br /> AID' FACF <br /> R CHECK kA6H RECEIVED BY DATE Be/PERMIT NUMBER NVOICE <br /> CODE FFYINTO AMOUNT RFN ITE <br /> 2-1 <br /> Pub.Health SeW.-Enviro.174(3/96) <br /> � )(7c+ mak- <br /> <no � - fou �C+CL�Cchce <br />