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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 952010388 <br /> (209) 488-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> [Complete in Triplicate) <br /> AFPUCATION IS HEREBY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WO <br /> gC DESCRIBED. THIS APP1CATbN IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 T�EAND THE STANDARDS OFSANJOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN4 Z�7+ ,/ S J A"t ck-roYL� l©^�Cp. ,/ CCrrY� a v y LOT <br /> SQE�Af%/LR+ <br /> OWNER'S NAME ("?,v CYIUiKA GLS..-ISC�! PDD11E66 / /O �� ^Y KEW - 6— RHONE 3427- I-740� <br /> -3e13 <br /> CONTRACTOR <br /> CONTRACTOR .��n-,%OYL �'C!�/T'L ADOREee/Z/C E�` �1� 111 al tics �15- [•HONE <br /> SUB CONTRACTOR T ADDRESS me <br /> TYPE OF GOMC WORK: NEW INSTALLATION REPMRIADgT10N ❑ DESTRUCTION ❑ <br /> ANO SEPTIC SYSTEM PRMITTEO IF PUBLIC SEWER IS AV I1-ABLE WITHIN 200 FEET OF BWLDING.1 PERC TIBET.)l 1 HOW MANY <br /> �� / I I APWicetlon i <br /> INSTALLATION WILL SERVE: flE61DENGE,6 COMMERCIAL ❑ OTHER❑ JT1 -F}D✓'1 V• <br /> NUMBER OF LMNO UNITS NUMBER OF 6EOROOMi: 3 NIaAaER OR EMPLOYEES: <br /> CH ER OF SOIL TO A DEPTH OF 3 FEET: Q!/^<F MMMP BOIL CHAAACTER: �i.�/IfeAoR l WATER TABLE DEPTH <br /> C TA EASE TRAP ❑TYPEMFG L-{ �e— CAPACITY IZBO Q�� NO.COMPARTMENTS oZ <br /> ��r <br /> ' TREATMENT MMT❑ DISTANCE TO NEAREST: WELL�6D A FOUNDATION /'�J ITDPEITIV LINE 7� <br /> UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) ) _ <br /> LEACHING UNE ')v NO.&LENGTH OF LINES - a STANCE TO NEAREST:WELL /OAS FOUNDATION LSA PROPERTY LINE 7S <br /> FILTER BED ❑WIDTH LFNGTN D PTAH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED `❑�WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> EE <br /> SPAGE PN <br /> TS DEPTH_SIZE -3(0 " NUMBER_ DISTANCE TO NEAREST: FOUNDATIONS PROPERTY LINE -16- <br /> SUMPS <br /> SSUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NFAPEST:WELL FOUNDATION PROPERTY ME <br /> DISMSAL FONDS ❑WIDTH LENGTH DEPTH DISEANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AN GU NS <br /> IF BAN JOAQUINCOUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT INTHE PERFORMANCE OFTHEWOIK FORWHICH is <br /> I6 PERMIT IS ALL NOT EMPLOY ANY PERSON IN S MANNER AS TO BECOME SUBJECTTO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR V` <br /> SUBLONTRACT SIGN IFIES THE FOLLOWING:'I ERT[ THAT IN THE PERFORMANCE OF THE NOR(FOO WHICH THIS PERMIT IS ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO Ci <br /> WOR(MAN'S CO N TI 5 CALIFORNIA.' THE ANT UST CALL 24 HOURS IN ADVANCE MR ALL.R�EQUIRED�RNSPKTIONS. COMPLETE DRAWING BELOW. (A <br /> SIGNED DATE: <br /> ' PLOT RAN[DRAW TO SCALE)SCALE .to <br /> 1. NAMES OF STREETS OR MST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISMISAL SYSTEM OR P OMSED <br /> 2. OUTLINE OF THE PFOPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE NSMISAL SYSTEMS. G <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROMISED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON p <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. I`C. <br /> ✓'-`5 <br /> _ �' 1@ctC� C.iQJ- C'''G� �rc�,•F'/�rsF:P�? 1C�/l���i -.'.- <br /> I , <br />