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APPLICATION FOR LIQUID WASTE PERMIT Sf� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERYfCEIAID# <br /> ENVIRONMENTAL HEALTH DIVISION OO <br /> P.O.BOX 388, 446 N.SAN JOAQUiN ST.,STOCKTON,CAL <br /> (2081468.3420 '/ /MO REFUN ABLE - a y rap pA `^( J I 'J x <br /> bCssPlstm is TrpGsata) lJ Fl(J� <br /> Application is hereby made to the San Joaquin county for a permit to construct and/or install the work descr <br /> is rude in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of son Joaquin County Public Health <br /> Services, Envirumntal cH-eaalth Division. <br /> Job Address/or APNS a��O - 1^, Z- j � ,l Cit Lot_Lot Size <br /> Owners Name �[� \� A\-eC I�Address � /� <br /> Contractor d I— hJL1'l V�—Address Lie/ Phone <br /> Sub Contractor Address Lici Phone <br /> TYPE OF SEPTIC WORN: NEW INSTALLATION Pte"—REPAIRIADDITION(I DESTRUCTION I) I=TESTW ill Now are;- 1 <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> Lass Use ApReaUen P <br /> Installation wilt serve: Residence Commercial_ Commercial `�other <br /> Number of living unites__ Number of bedroonat Number of aaployeos;—� o <br /> Character of soft to a depth of 3 feet: h V it/Sump Soil Charaatar:„ 02 MUoter Tab-to Depth <br /> SEPTIC TANIUOREASE TRAP e/�[) Type/Hfg "Ti— .a ? <br /> p V. Capacityc"'{lo oy/No. Caapart■srmta <br /> PXO TREATMENT PLANT01A Distance to nearest: Well " Foudatfor;q,_ Property Ifnr- , <br /> LIFT STATION[J Size_Type of Pump Send Oil Separator (enclosed system) <br /> LEACHING UNE [I No. A Length of lines 3 /0 / Distance to Nearest: Wet l 0 0+FoundatIw6ZQO Property Lirw IS— <br /> FILTER GED O Width Lergth Depth " Wall Foundation Property Line /. <br /> MOUNDED [3 Width Length Depth ° " Well Foundation Property Line--+- <br /> SEEPAGE <br /> ine -+- <br /> SEEPAGE MTS D Depth Size Number " " Well Foundation Property Lina + <br /> SUMPS [) Ufdth length Depth " " Wall Foudation Property Line <br /> DISPOSAL PONDS U Width Length Depth " " Well Foundation Property Line <br /> 1 hereby certify that I 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 Sen Joaquin County. Home owner or licensed agent's signature certifies the following <br /> • "[ 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 taws of California." Contractor's hiring or sub-contracting signature certifies the--r- <br /> following: <br /> he=following: "I certify that in the performance of the work for which this permit is issued, 1 shalt stmptoy persons subject to workman's <br /> compenua California." <br /> Tb swat 010A Mrs is r am ragdrwf sMastiass Complete drawing below. � /�'— /y 'C <br /> signed % Title•.--/ V Dates <br /> PLOT PLAN (Draw to Scott) Srate,�_" to yd �- <br /> 1. Nam" of streets or roads nearest to or bounding the property. 4. Location of hale sewage disposal system or <br /> 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage disposal systesa. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wefts. within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> LAf <br /> p <br /> n <br /> p p y T <br /> ro R CE IV D <br /> AU <br /> 5 <br /> MJ <br /> NC 11N' <br /> EAL MDI I$10 <br /> 4 <br /> n [� <br /> Fib c .1vC+S f m N b Cil cQ• FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date: Area: <br /> Tank, Pit or Sunp Inspection by Date / / Final Inspection by Date / 9L/ <br /> Lp <br /> Additional Comments: Q - �gyr�y�J <br /> ACCOUNTING gMIY: AID/ FACti `'e �` ""O'1/� <br /> o� <br /> PEyC}DOE FEE INFO AMOUNT REMITTED NEC CASH RECEIVED BY DATE SR 1 PESMIT NUMBER INVOICE/ <br /> 377 <br />