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yr APPLICATION FOR LIQUID WASTE PERMIT "� J <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> )209) 468.3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Cempleh in Triplicate) <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAMIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHA�PTTEER�9-1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIC/EB,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APR/ '� / / ♦ / V A�yl,��IhJ CITY k-V LOT SIZE_ <br /> OWNER'S NAME^4l +'`+ I 1 L )!Fes,()P t% ADDRESS {�� /,_ RHONE <br /> CONTRACTOR I v� (-_ ADDRESS r4/1 E_� c - PQ AtF"f/J LIC/ PHONE � ! U <br /> .SUB CONTRACTOR ADDRES6 <br /> LICI RHONE <br /> TYPE OF SEPTIC WORK: NEN INSTALLATION ❑ REPAIRIADDHTION DESTRUCTION ❑ <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 300 FEET OF BUILDING.( PEIC TESTNI 1 I NOW MANY <br /> I} <br /> APMIPSMSn/ <br /> INSTALLATION WILL SERVE: RESIDENCE A' COMMERCIAL ❑ OTHER ❑ <br /> 4UMBEA OF LIVING UMTS: NUMBER OF BEOROOMe: MUMMER OF 9NROYEES: 1 If \ CL <br /> _:HAMCTER OF SOIL TO A DEPTH OF 3 FEET: C Q. RLE TISUMP BOIL CHARACTER: WATER TABDEPTH Ian S <br /> SEPTIC TANKIOREA6E TRAP ❑T`/PE./AIFD CAPACITY NO.COMPARTMENTS <br /> MLO TREATMENT RANT❑ DISTANCE TO NEMUT: WELLFOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PIMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI <br /> "IUCNNO LINE A NO.M LENGTH OF LINES ��� DISTANCE TO NEAREST:WELL/X1-6' FOUNDATION y� PROPEnry LINES <br /> FILTER BED A WOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE C1 <br /> ROUNDEDD MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIRE <br /> r EEPAOE RTS WDEPTHy;2SIZE y� NUMBER_L DISTANCE TO NEAREST:WELI/O��FOUNDATION y0 Y- PROPERTY UN-zl2L:%• <br /> SUMPS ❑WIDTH _LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION ROPERTy LINE Fy <br /> IISMSAL MMOS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> �'T HEIIEBV CERTIFY THAT 1 HAVE PREPARED TH19 APPLIOATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE BAN JOAMIN COUNTY.HOME OWNER OR LICENSED AGENT'R SIGNATURE CERTIFIES THE FOLLOWING:')CERTRYTHAT IN THE PERFORMANCE OF THE WOR(FORW RICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN OUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTMCTOR'S HIRING OR <br /> UB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOO WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> VORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> SIGNED X V - 37� TITLE:��(�J!J Y,N w,n-I,�— DATE: <br /> G� <br /> PLOT RAN RDRAW TO SCALE)SCALE 'lP <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE REWAGE DI6MM SYSTEM OR PROPOSED <br /> 1. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND MONTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, e. LOCATION OF WELLS WITHIN MINUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> If <br /> S <br /> 00 <br /> t <br /> _ Ar cj� <br /> � � h <br /> 1 c ; <br /> IT <br /> j'R.C6V f; 1 <br /> �, <br />