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APPLICATION FOR LIQUID WASTE PERMIT
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> JUN 2 g 2000 ENVIRONMENTAL HEALTH DIVISION
<br /> P.O. BOX 388, 445 N. SAN JOIN ST., STOCKTON, CA 95201.0388
<br /> ENVIRONMENT HEALTH (�� ,(209T) 49A
<br /> 00 -3420
<br /> PERMIT/SERVICES LI 110N•REFUNDABLE PERMIT EX IRES 1 YEAR FROM DATE ISSUED
<br /> I (Complete in Triplicate)
<br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN
<br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1110.3 AND THE S ANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.
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<br /> JOB ADDRESS/OR APNI CITY ' LOT
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<br /> OWNER'S NAME ; I i'uf L -4 ADDRESS �•�,[ -.`• U - f ,NE 33 Y 7�Z
<br /> CONTRACTOR - lG [r �KTt,I ADDRESS /�f`�(/'r /1(,.•�L. ? �J 1'a�''f`' U�,Fy 5 ON 2-313
<br /> SUB CONT TOOADDRESS (-J(,\ Ll� �' + l UC# PHONE
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<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION
<br /> (NO SEPTIC SYSTEM PERMRTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING. PERC TESTI@ I 1 NOW MANY
<br /> ApplicationI
<br /> INSTALLATION WILL SERVE: RESIDENCE 1:1COMMERCIAL OTHER ❑ '
<br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:
<br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET. f Ii1, PITISUMP SOIL CHARACTER: WATER TABLE DEPTH ,) (7, ��f L J'
<br /> SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS _T
<br /> - PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE
<br /> UFT STATION❑ SIZ TYPE OF PUyM�P(' SAND OIL SEPARATOR(ENCLOSED SYSTEM)
<br /> LLEACHINGUNE NO F LINES_ V 1 r Fs C:3 1['4t I'I� I'DISIANCE TO NEAREST:WELL.el f2(-j q FOUNDATION • a 0 PROPERTY LINE x•�1�•
<br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE
<br /> SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION 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:'I CERTIFYTHAT INTHE PERFORMANCE OF THE WORK FORWHICH
<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
<br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWI 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO
<br /> WORKMAN'S COMPENSATION
<br /> LAWS OF CALIFORNIA. APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. rte,
<br /> SIGNED X "'- 1 C, '1/Y TITLE: Y�)C.C, l�•r7 DATE: fY V�lI
<br /> PLOT PLAN(DRAW TO SCALE)SCALE •to
<br /> 1. NAMES OF STREETS 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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON
<br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIKsc THE PROPERTY OR ADJOINING PROPERTY.
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<br /> APPLICATION ACCEPTED BY - W _ E: �✓ AREA:
<br /> TANK,PIT OR SUMP INSPECTION BY c �— --- DATER '- „ ' [NSPECTION BY DATE
<br /> ADDITIONAL COMMENTS: LI �4 — ^Z,xx, !" " F ) P9
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<br /> ACCOUNTING ONLY: AID# FAC#
<br /> PE CODE FEE INFO AMOUNT REMITTED CHECK 1 ASH RECEIVED BY DATE SA/PERM 8� INVOICE#
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