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APPLICATION TOR LIQUID"WASTE PER l <br /> SAH JOAaUIN COUNTY PUBLIC HEALTH St..1iCES <br /> i ENVIRONMENTAL HEALTH DIVISION <br /> A.O. BOX 388, 4411 N. SAN JOAQUIN ST., STOCKTON, CA 95201-0386 <br /> {209} 468-3420 <br /> �NON•REFUNI)ADIE PERWT EXPIRES 1 YEAR FROM DATE ISSUE <br /> I ' lComplets in Triplicate) <br /> Application is hereby made to the San Joaquith County for a permit to construct and/or instalt the wdrk described. "This application <br /> is made in compliance with San Joaquin County.Development.Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public-Heatth <br /> Services, Environmental Health DiviSion. � <br /> i <br /> Job Address/or AP City Lot Size <br /> Owner's N t ddr�ss `�� Phone <br /> ire ' r y,T1 T_Z1 d <br /> Contractor � '&/ Address a�'f�.-t�76 7 z �L'ic# <br /> Sub Contractor Address Lic# Phone <br /> TYPE OF SEPTIC NEW INSTALLATION 1.I 1 EPAIRiA ITIOII,#11 DESTRUCTION I) PERC TESTle1 I I How men <br /> (NO SEPTIC SYSTEM PERMITTED-IF PUBLIC SEWER IS AVAI E WITHIN 200 FEET OF BUIL'DING.) " <br /> Land Use Application# <br />' Installation will serve: Resldence-,y—; Commercial Other <br /> Number of living units: f Number of bedroome:� Nuriber"of employeos: <br /> Character of soli to ■ depth of 3 feet: Pit/Sump Soil Character: Water Table Depth (t o <br /> SEPTIC TANKIOREASE TRAP, i) Type/Mfg Capacity No. .Compartment* <br /> �l <br /> PKO TREATMENT PIANT E l Distance to nearest: Well Foundation Property line <br /> LIFT STATION[]! Size Type of Pump Sand Oil Separator (enclosed system) <br /> LEACHING LINE , Q No. & length of "lines Distance to Nearest: Well Foundation Property Linp_ <br /> FILTER RED 11 Width Length I Depth " i' Well Foundation Property'Line <br /> MOUNDED 0 Width Length Depth_ t " Well Foundation Property Line <br /> 1 " Well oc+� Foundation IC/ Pro rt Line 5� <br /> SEEPAGE PITS Depth-2-5— Size: -„Number J pe, y _ <br /> SUMPS ❑ , WidthI Length Depth ” !' Well Foundation Property Line <br /> f DISPOSAL'PONDS, [I Width Length 1 Depth at " Well Foundation Property Line . <br /> i hereby certify that i have prepared this application and"that the work will be done in accordance with San Joaquin County Ordinances <br /> aril State Laws, and Rules and Regutat,ions{of the San'Joaquin County. Home owner or Licensed agent's'signoture'certifies the following <br /> "I certify that in the performance of the work for which this permit is issued,.1 shall not employ any person in such a mariner as" <br /> to become subject to workman's compensatlion' Laws of California." Contractor's hiring or subTcontracting signature certifies the <br /> l}✓ following: "I 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 Califorriis." <br /> V The applicant must call 24 hours Is advance for all rl gained Inspections. Complete drawing below. <br /> V Signed X X21 Title: l-L.r_, Date: SAE ' <br /> i <br /> PLAT PLAN (Draw to Scale) Scale It 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 disposat systems. <br /> 3. Dimensioned outtines and location of}all existing and proposed, 5. Location of wells within radius of 150, ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining'.property. <br /> and walks. <br /> X <br /> i <br /> i <br /> FOR DEPAR MENT USE ONLY <br /> Application Accepted by E Date: Area: Cr f <br /> Tank, Pi' or"Sump Inspection byDatfgA§3�?�inat 'Inspection by at g <br /> r <br /> Additional Comments'; 1 " <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE FEE INFO AMOUNT REMITTED '6utI:1t7ICASH RECEIVED BY DATE ION J PERMIT NUMBER INVOICE 1 <br /> Zt q 7,5 <br />