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v <br /> APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N. SARI JOAQUIN ST., STOCKTON, CA 96201-0396 <br /> (2091468-3420 <br /> l <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FRONT 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 4-1110.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN# / i �rG -------City , •�� Lot Size <br /> wner's Name Address ZC3 6' _ �/�'�r yy L✓r^ _ Phone3 433 <br /> C o n t r a c t o J, * r Address 71,"7' 1J ZY Lic# :Wd Phone- <br /> Sub Contractor Address Lic# Phope <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION I 1 DESTRUCTION I I PERC TESTIS)I I Haw manly <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> Land Use Application B <br /> Installation will serve: Residence Commercial other <br /> Humber of living units:____ Number of bedrooms: L Number of employees: <br /> Character of soil to a depth of 3 feet: ! ,4g., Pit/Sump Soft Character: _ f ! Neter TabLo Depth--- -Qk,�}' <br /> SEPTIC TANISIOREA8E TRAP Type/Mfgs u7 Cepeclty GNo. Cormpertnaenta -2 <br /> PKG TREATMENT PLANT [ ) Distance to nearest: WetlI r,,., `Foundation Property tine E-,6i <br /> tl <br /> LIFT STATIONEl Size Type of' Pump Sand Oil Separator (enclosed system) <br /> LEACHING LINE No. & length of lines 3 D Distance to Nearest; Wali 5Q. Foundation AS' Property Line to' <br /> __..__..�._._ � � Y Lam_ <br /> FILTER BED [I Width Length Depth 11 '° Well Foundation Property Line <br /> MOUNDED 11 Width Length Depth " 11 Well Foundation Property Line <br /> SEEPAGE PITS Depth , size462 Number 5 11 °° Well &0j' Foundations Property Line <br /> " SUMPS [] Width Length Depth 1° a Well Foundation Property Line <br /> DISPOSAL PONDS 11 Width Length Depth 11 °° Well Foundation Property Line <br /> JI 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. Home 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 shall 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: 111 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's <br />' compensation laws of Catifornia.11 <br /> The applicant ritual call 24 hours In adv a for all required Inspections. Complete drawing below. <br /> Signed X � 1 Title: : Date: 0d f <br /> F ± <br />� <br /> PLOT PLAN (Draw to Scale) Scale 11 to ` 1Fs"�� <br /> r 1. Names of streets or roads nearest to or bounding the property. 4. Location of ho*0 f'e Ni jlo l system or <br /> 2. Outline of.the property, with dimensions and North direction. proposed expansfon o�sew6ge d,Agposal systems. <br /> # 3. Dimensioned outlines and location of all existing and proposed 5. Location of welrn <br /> 'Ps" thin,'raiiEWs of 150 ft, on <br /> structures, including covered areas such as patios, driveways, the property or adjoining pro�erty..�, <br /> IC and walks. :aF: .;; ll <br /> I S ' <br /> t <br /> I i <br /> l 1 <br /> � ��1 <br />