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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> -29'716 {7-fk -f- (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICempbto In Triplkntol <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL TIIE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNT`/DEVELOPMENT T(TLE,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH BE ES,ENVIRONMENTAL HEALTH DIVISION. <br /> D'. <br /> JOB ADORESBIOR AP`N/ {�•, t CITY �`(� LOT SIZE <br /> 6rl el <br /> OWNER'S NAMEy�' `'1 1�1 It1w I�-[l jADDRFSS , - '� ;,;,a o ��`^ �`-�• _ P, �(P— '-f 0D <br /> 0� <br /> CONTRACTOR LAS ADDRESS LIC/ PHONE <br /> OUR CONTRACTOR Jk. ADDRESS UC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION ❑ <br /> IND SEPIIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW 1 I HOW MANY <br /> ` AppKpMMon I <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALS OTHER ❑ �/ <br /> NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: \JGl S 1-` ��..� �✓ <br /> CHARACTER OF SOIL TO A DEPTH QFFp9-F�EE�T�:� PrT/SUMP SOIL CHARACTER: f WATER TABLE DEPTH <br /> SEPTIC TANK/ORFASE TRAP IO.TT/PE/MFO �f 4L CAPACRY 2-���-�`� NO.COMPARTMENTS <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL V IJr FOUNDATION PROPERTY LINE� - <br /> LIFT STATION❑ 917F TYPE OF PV P J AND OIL SEPARATOR(ENCLOSED SYSTEM( l5,"- <br /> ����----yyyy������� /0 DISTANCE TO NEAREST:WELL va FOUNDATION b L'ROi'E(TTY UNE l <br /> LEACNNO UNE pJ10.S LENGTH OF LINES �`ba �- <br /> FILTER BED /❑_WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> DUMP$ ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION R4ROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE n <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK W11L BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULE9 <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR UCENSFO AGENT'S SIGNATURE CERTIFIED THE FOLLOWINO:'1 CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK FOR WHICH <br /> THIP PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING O <br /> SUB-CONTRACTING SIGN TURF CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I-ISSUED.1 SH/111 EMPLOY PER. SUBJECT TO <br /> WORKMAN'S CoMPENBA N LAWS OF CAUFORNIA.' THE A►PUCANT MUST CALL 24 HOURS IN ADVANCE FOR REQUIRED INSPECTIONS. COMR'LETE WINO BELOW. l <br /> N .� THLE. !-7 �(/v B L�-4 7"✓DATE: <br /> SIGNED% — <br /> PLOT PUN(DRAW TO SCALE)SCALE_ '10 <br /> III <br /> 4 <br /> r —Uaenas• I ---- _ I4" C <br /> - - ------- �- i <br /> i BOR( N -�� �_ o�_ - ;,r:. L W L 1 <br /> O. <br /> ( <br /> J4�..... <br /> r <br /> �l7 <br /> 00 — <br /> 12 <br />