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APPLICATION FOR LI(IUID WASTE PER
<br /> SAICJOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> P.O. BOX-388, 904 EAST WEBER AVENUE, STOCKTON, CA SM14W
<br /> (209) 488.3420
<br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> IC$mpl$t$in Triplkats)
<br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN
<br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 5-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIF40NMENTAL HEALTH DIVISION. C
<br /> JOS AbbRESSlOR APN# 153 I Z• J
<br /> ,1 �iY G ^ ,[., CITY L�N.� LOT SIZE_L44VE-fj
<br /> OWNER'S NAME IWV�i-� , r1��ON ADDRESS -J� f ✓iSJ, tL1�^�Y�jD�+� � - PHONEp�y3 *-1� 1
<br /> (� ..._. .ADORES$ �b�d5 yILVYI�GrIi� l.�-�5E---LIC# I�3Z5_`� PHONE -1-J��LL' �
<br /> CONTRACTOR_1 �i'DVT'&L12.-__
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<br /> SUBCONTRACTOR I ADDRESS LIC# PHONE
<br /> I TYPE OF SEPTIC WORK: NEW INBTALLATIO Ii j, REPAIRIADDITION ❑ DESTRUCTION ❑
<br /> MO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN,TOO FEET OF BUILDINO.1 POW TESTIA[ 1 HOW MANY
<br /> Application f
<br /> INSTALLATION WILL SERVE: RESIDENCE R COMMERCIAL❑ OTHER❑
<br /> NUMBER OF LPANG UNITS:,_---�--_ NUMBER OFBEDROOMS: NUMBER OF EMPLOYEES;
<br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: UAV)D4 1 4,Q+�'.7 kTISUMP SOIL CHARACTER: t tw ,/I LD -rWATER TABLE DEPTH 19191D1 ry
<br /> r :SEPTIC TANKIOREASE TRAP 91 TYPElMFO�GON C-F- E/ y4 L- CAPACITY !1 sL I Q1J NO.COMPARTMENTS (�
<br /> PLCO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL 7T— FOUNDATION 3t-�'A PROPERTY LINE �� J
<br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM)
<br /> LEACHING LINE NO.&LENGTH OF LINES '�' p DISTANCE TO NEAREST:WELL / FOUNDATION „ PROPERTY LINE 50
<br /> -FILTER BED ❑WIDTH LENGTH' DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> MOUNDED 13
<br /> WIDTH LENGTH' DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE
<br /> SEEPAGE PITS I$DEPTH SIZE,
<br /> !f NUMBER �✓ DISTANCE TO NEAREST:WELL s�Z FOUNDATION PROPERTY LINE
<br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> ,.DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST: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 AND STATE LAWS,AND RULES
<br /> AND REGULATIONS Of THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH `--r
<br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR ,n
<br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWNIG:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO l/
<br /> WOPKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL
<br /> REQUIRED,I[NSS�P.ECCTIIO�,N$$. COMPLETE DRAWING BELOW.
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<br /> SIGNED X DATE: !Z�I
<br /> PLOT PLAN(DRAW TO SCALEI SCALE 'to
<br /> 1. NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED
<br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.
<br /> 3. DIMENSIONED OVTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON
<br /> THE PROPERTY OR ADJOINING PROPERTY,
<br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS.
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<br /> L Std fi`� fAr�k ..
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<br /> FOR DEPARTMENT USE ONLY 7 ¢ /,' /
<br /> APPLICATION ACCEPTED BY4exLDATE: r DEA:_ �Y oy'
<br /> TANK,PIT OR SUMP INSPECTION BY DATE 1 1 FINAL INSPECTION BY DATE 1 ,7or
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<br /> ADDITIONAL COMMENTS:
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<br /> ACCOUNTING ONLY; AID# FAC#
<br /> PE CODE FEE INFO AMOUNT REMITTED C 1CA&H RECEIVED BY DATE SR I PEf 7MIT NUMBER INVOICE 0
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