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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.SOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201.0300 <br /> (2091460-3420 <br /> MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICDmpMtB in Triplk.tFl <br /> APPUCATIGN IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIGR INSTARTHE WORK DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAN <br /> e•.. LOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-7110.3 AND THE SYANDAPDS OF SAN JDAOIHN COOKN PUBLIC HEALTH SERVICES.ENVIRONMEENFLL HE <br /> TAALTH OIVLSIGN. <br /> I..ADDRE89fOR APNT CFF-���IV L2 LJf/ LOT SIZE <br /> OWNER'S NAME G� ADDPE59�-:204Ad <br /> cGNrRACTDP� <br /> Y1OlTK �/�S ADORESB UC�NB �� <br /> SUB COM'RACToR ADOPEGB LC. R1a NE <br /> TYPE OF SEPTIC WORK: NEW 1wumAnox 13 REPAI VADLNTION DEATRLKTIGN❑ <br /> INO SEPTIC SYSTEM PERMITTED 1F PUBLIC SEWER IS AVAILABLE}NITHiN 290 FEET OF..MAIN.i P6RC TESTI.1 I I NOW MANY <br /> ,�/ - AFPEaABOR <br /> • <br /> INSTALLATION WILL SERVE: RESIDENCE IA COMMENCSAL E3 OTHER 0 <br /> NUMBER OF WINO RRVITcI_�NUMBOR OF BEDROOMS; NUMBER OF IMPLOYEES: "5'R57 — <br /> CHAMGTER OF SOIL TO A OLFTN OAF 3 FEET��PrrxumP SOIL CHARACTER;,, t L; M� - WATERTABLE DEPTH <br /> SFPTIC TANKICREAGE TRAPBU ONPFIMFD CAPACnY NO.COMPARTMENTS <br /> PKO TREATMENT PUNT❑ DISTANCE TO NEAREST: WELL FOUNDATION IROFERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR{ENCLOSED SYSTEMS - f <br /> �f .A <br /> LEACHING LINE Yi NO.A LENGTH OF LSNES���—DISYANCE TO NEAREST:WELL�LFDUNDATION�,,.,�� .11111UNE�2 <br /> III ALTER am ❑MDT" LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION FROPERTY UNE <br />` MOUNDED L7 WIOTH LENGTH DEPTH DISTANCE TO MEANEST:WELL�r FOUNDATION PROPERTYLINE <br /> l RFSPAOE N- �DEPRH_��r EIZE , n-—NUMRER, DISTANCE TO NEAREST-WELL��•'�"FOUNDATIGN_ PROPERTY UNE–A?9C2f— <br /> l SWAPS ❑ VUTH LENGTH DEPTH DISTANCE TO NEAREST:WFLLFOUNDATION PROPERTY LINE <br /> NISPOSAL PONDS ❑MOTH LLNGTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTYUNE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK NULL BE DONE IN ACCORDANCE HATH SAN JOAOUIN COUNYY ORDSHANCFS AND.?ATE LAWS.AND RULES FVVVO-LLL))) <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER 00 OCENSED AGOP T <br /> ENT'S SIGNATURE CERTIRESTHE FOU-OMNG:'I CERTIFYTHAT INTHE PERFORMANCE HT WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUB <br /> TO WOAKMMT COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HINNOR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT 1S IGSUm,1 SHALL EMPLOY PERSONS SUB TELT TD <br /> WDM MAN'S COMPENSATION UWS OF C'LIFORNM.' CANT MJSY CALL SA IRIS NK 1N ADVANCE FOR ALL RESUMED INSPB;IRONS.COMPLETE DRAWING BELOW. <br /> I SIGNE • TITLE: DATE: -- �•. !r, <br /> ROT PLAN IORAW TO 6CAIE7 SCALE 'to <br /> 1.NAMES OF STPFEFS OR ROADS NEARFSTTO CRBOUNOWO THE PROFERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z,fIUTUNE-OF THE PROPERTY,WITH DIMENSIONS AND NORTH OIPECTION. EAPANSIDN OF SEWAGE DISPOSAL SYSTEMS. <br /> I 1,DIMENSIONED OUTLINES AND LOCATION OF ALL EIGGTING AND PROPOSED STRUCTURES, 6 LOOAYN)N OF WELLS WTBHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> ' INCLUDING L.VERED ARE _ LKS. <br /> THE PROPERTY OR ADJOINING PROPEM- <br /> 7– <br /> I <br /> Is <br /> IL <br /> Z <br /> o ... ..::-.. .. .. j` <br /> ... .,.-. <br /> -- ... ... EN I <br /> p <br /> - W . <br /> { dF U04 <br /> ....-.. - Ji4 <br /> ALTH 1, <br /> FOR DEPARTMENT USE ONLY - <br /> L APPLICATION ACCEPTEG RY DATE: ' A //r�L <br /> TAM,PT'OR SUMP INSPECTION BY DATE `f 1 FINAE INSPECTION B �— DATE 6 1 !A]!'I <br /> I ' <br />[ ADDITIONAL COMMENTS:` <br /> ACCOUNTING ONLY: AID. FAC. <br /> iiiFFF PE SODE FEE INFO AMOUNT REMITTED C C ASN RECEIVED BY DATE SR f PERMIT NUMBER LNVOIGE 1 <br /> I �i <br />