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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, 304 EAST WEBER AVENUE, STOCKTON, CA 9,,201-388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICampletl in Triplicate) <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPUANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.33 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> J08 ADDRESS/OR APNA �lh -� ly-I V C`+�' 15 r ,1'�Cr,t (,�}�y LOOT 612E1-' <br /> OWNER'S NAME - �6 C/-1 ADDRESS S yy Rt/ f C PHON p-- <br /> CONTRACTOR <br /> 7?'A ADDRESS_ 7fnC1 .3C�f, 7C�I-IN/jGE'/�f/LCA' N�. �1(�1 O C �L•' I G`S5 <br /> SUB CONTRACTOR ADDRESS UCI LONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPANVADDITION ❑ DESTRUCTION ❑ - / <br /> IND SEPTIC SYSTEM PERMITTED If PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIO I I HOW,N}ANY <br /> L <br /> � Avdoetl <br /> lon t <br /> flYiv <br /> INSTALLATION WILL SERVE: RESIDENCE GP COMMERCIAL ❑ OTHER ❑ r e e-pnm f-c-"jo' -- <br /> NUMBER OF UVING UNITS:--L— NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> r <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: ,-t <br /> WATER TABLE DEPTH l <br /> SEPTIC TANK/OREASE TRAP ❑TYPE/MFO CAPACITY NO.COMPARTMENTS <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING UNE ❑ NO.At LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> SUMPS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> :NSPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WFLL 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 AND STATE LAWS,AND RULES <br /> ',ND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE Of THE WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR <br /> 3U8-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> -WORKMAN'S COMPENSATIO WS OF CALIF IA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> ;IGNED X <br /> PLOT PLATITLE:N(DRAW TO SCALE)SCALE 'to DATE <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br /> OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSE[) <br /> �. <br /> DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTVRE 6, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> --- - THE PROPERTY OR ADJOINING PROPERTY. <br /> Ii — <br /> �Q.45G <br /> I <br /> t-L y <br /> - J - <br /> i <br /> F I 4-_ r_... <br /> __� j . _ - <br />