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lal-7 APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 962010388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM 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 9-1110.3 and the Standards of San Jooaqui�nty Public Heat th <br /> Services, EnvirormentaL Health Division. /J ) I n,9 C'O r-1 _ I (' o S <br /> Job Address/or AAPPN# 11�/ l' 7 ///?//prtj 9J. City I ,yPr, Lot Size � ✓)C <br /> Owner's Name TKI�k� J3e /� Address 5hWIC'_ �,/ Phone�J-` <br /> Contractor [f,"knlL NYlf, lc,r y Address ��'{- � �(� f�4,C-- DW— Lic# Phone 5< "Z7 <br /> Sub Contractor Address Lic# Phone <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION b(, DESTRUCTION I I PERC TEST(s)I I How many <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> Land Use Application Y <br /> Installation will serve: Residence, Commercial_ Other_ <br /> Number of living unitrt__I__ Number of bodrooma: Number of employees: <br /> Character of soft to a depth of 3 feat: d q Plt/Sump Soft Character: - YTY I Water Table Depth <br /> �5 TIE TANKIGflEASE TRAP [] Type/Mfg Cepad[y No. Compartments <br /> PKG TREATMENT PLANT ( ] Distance to nearest: Wait Foundation Property line <br /> LIFT STATION[] Size_ Type of Pump Sand Oil Separator (enclosed system) <br /> LEACHING LINE 14 No. 8 length of lines '— v _f-S'{Z Property �Ci*) <br /> y� Distance to Nearest: WeIL foundation $—(� Pro rt Line -)- <br /> FILTER BED I] Width_ Length_ Depth " " Well Foundation Property Line <br /> MOUNDED [] Width Length_ Depth " " Well Foundation Property Line <br /> SEEPAGE PITS 11T.. Depth '4S Size 3>." Number I Well 175 ' Foundation 1601 • Property Line <br /> SUMPS ❑ Width_ Length_ Depth " " Well Foundation Property Line <br /> DISPOSAL PONDS ❑ Width_ Length Depth " " well Foundation Property Line <br /> I hereby certify that 1 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 /> "I 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 laws of California." Contractor's hiring or sub-contracting signature certifies the <br /> following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's <br /> compensation laws of California." <br /> The applicant must call 224 hours in advance for all required inspections. Complete drawing below. <br /> Signed X�.�G.. -. TItIe:=�!!�'^C.CCSDate: U <br /> PLOT PLAN (Draw to Scale) Scale " to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> — 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of waits within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> A- r� <br /> JA AN 44� <br /> E I r I <br /> 1 ' <br /> a � � <br /> e <br /> j7flt ve LTJ <br />