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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ;! '`Q ,I<f, R .d.: <br /> ENVIRONMENTAL HEALTH DIVISION "�-= <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 465-3420 MAR 2 2 1999 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> TH <br /> (Complete in Tliplksts) <br /> APPLICATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPM <br /> EN <br /> T TITLE,,CHAPTER <br /> R99-11 10.3 AND THE STANDARDS OF SAH JOAOVIN COUNTY PUBLIC HEALTH <br /> /]SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNI ` /t v!�,/✓`/� / ' 2'T { ' 1 CITY IY C4- LOT SIZE <br /> OWNER'S NAME /e!v ""/ `/l—/AIYt ADDRESS t//�t e PHONE <br /> CONTRACTOR <br /> UCS/+N/� WADS ADDRESS Q� TVJ o Uc/ d7j 21 5PHONE �`ZVf�9 77� <br /> SUB CONTACTOR ADDRESS <br /> L1CI PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIORS DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW I 1 HOW MANY <br /> App*o don i <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL 4 OTHER ❑ <br /> NUMBER OF LRRNO UMTS: NUMOM OF BEDROOMS: NUMBER OF EMPLOYEES: -;T- <br /> CHARACTER OF SOIL TO A DEPTH OF J FEET`' - / UM SOIL CHARACTER,�iV (c+ / �- WATER TABLE DEPTH <br /> �c CAPACITY NO.COMPARTMENTS <br /> SEPTIC TANK/OREASE TRAP E3TYPE/MFO`'y <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL <br /> FOUNDATION PROPERTY UNE <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING UNE ❑ NO.l LENGTH OF L1NE6 N <br /> DISTACE TO NEAREST:WELL D FOUNDATION �- PROPERTY LINE 574 <br /> FILTER BED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL <br /> FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> ❑DEPTH <br /> SIZE_NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE PITS <br /> LUMPS -W1DTH�•��LENGTH_1_ __DEPTH / 1./ DISTANCE TO NEAREST:wELL,�;V F'OUNDATIOFOUNDATION •f'Jz�Pp�RTY LINE_PROPERTY LINE <br /> DIS ❑W <br /> POSAL PONDS IDT" LENGTH DEPTH DISTANCE TO NEAREST:WELL <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAH JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE LAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'e SIONATURE CERTIFIES THE FOLLOWINO:'I CERTIFYTHAT BN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED.1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAW!OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> OF THE WOW FOR WHICH THIS PERMIT 18 <br /> WOWm OIM SIGNATURE <br /> LAM OF CALIFORNIA,'NTHE •IIAPPOCANT MUST CALL PERFORM CERTIFY THAT IN THE HOURS N ADVANCE FOR ALL REOURED INSPECTION$-ICOMPLM DRAWING BELOW.SSUED,104ALL EMPLOY PERSONS SUBJECT TO <br /> TITLE: O�{2�j DATE: <br /> SIGNED% <br /> OT PLAN(DRAW TO SCALE)SCALE 'to <br /> 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 1. NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 5• LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, THE PROPERTY OR ADJOINING PROPERTY. <br /> INCLUDING COVERED AREAS SUCH A8 PATIO$,DHIVEINAYB,AND WALKS. _. <br /> • ............................... 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