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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, MCKTON, CA 95201388 <br /> (209) 4883420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplkebl <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 DEVELOMM"WT TITLE,CHAPTER 8-1110.3 AND T "AN <br /> SOTS <br /> //A�J�I JOAOU&•}�.�rJnlly/[TV\J%IBLIC HEALTH/S./SJ�ftVIICC}}E�-S,,,,,EN"PPIONMENTAL HEALTH DIVISION. �A,� f <br /> JOB ADDRESS/OR APNF tT 3`-� �-^-'L��lele sem,. r� CITY / rC�o LOt(�61ZE_�-. T <br /> OWNER'S NAME O7�'L =c�L' Com- ADDRESS `J'T(7�1X., L//,// PHONE .RyO- (/ 7T�� <br /> CONTRACTOR ��Z /CryL .J� C_- ADDRESS/ZI C C"L'�L�/lr �- LIC( r711el- ' PHON�4'3 �J J4''� <br /> SUBCONTRACTOR ADDRESS LICI PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPa IVADDITION D"MMTION ❑ <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF RLI INGJ PERC TESTW I 1 HOW MANY <br /> '��-�//� APplaetlan <br /> INSTALLATION WILL SERVE: RESIDENC q0.� COMMERCIAL ❑ ? OTHER ❑ <br /> NUMBER OF LIVING UNITS:_ MVA/SFR OF BEDROOMS: 3 NUMSER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEE-ryG' Kis NT/SUMP SOIL CHARACTER ' A WATER TABLE DEPTH 1 cs-yJ 4- <br /> SEPTIC <br /> SEPTIC TANK/OREASE TRAP ❑TYMIMM CAPACITY NO.COMPARTMENTS <br /> PKG TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI <br /> LEACHING UNE �NO.•LENGTH OF LINES DISTANCE TO NEAREST:WELL,y FOUNDATION PROPERTY LINE /'C() <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTN LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> SEEPAGE NTS DEPTH SIZE 3� , NUMBER "� DISTANCE TO NEAREST:WELL IC*� 1 FOUNDATION -7Q r PH014RTV LINE l f'Lr r <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WFFH SAN JOAQUIN COUNTY ORDINANCES AND STATE"We,AND RULES <br /> AND REGULATIONS OF THE BAN JOAQUIN COUNTY'.HOME D ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:*(CERTIFNTHAT IN THE PERFORMANCE OF THEWOFK FORWMICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSONUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> SUBCONTRACTING SIG RE CERTIFI <br /> RKES THE FOLLOWING 9 ERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO <br /> WOMAN'S CO TION BOF CALIFORNIA.' THfAPFAIICANT MUST CALL 24 HOURS IN ADVANCE FOR(/ALL <br /> ,,RE�O1/µ1URED IMePFCTONe. COMPLETE DRAWING BELOW, 1 /JL/(J <br /> SIGNED X �� TITLE: \_U✓�` DATE: / -- LP L V <br /> \ PLOT RAN(DRAW TO SCALE)SCALE 'to <br /> 1. NAMESOFJ RE 1 ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOBAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE OISFOSAL SYSTEMS. <br /> J. 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 WALKS. THE PROPERTY OR ADJOINING PROPERTY. 1 <br /> AA It K <br /> N I I I <br /> 11 <br /> `L <br /> 1.L. ` <br /> � r. <br /> JUL 16 1993 <br /> ' aRw JLIIaUtJfN tlUfill i'r <br /> PARI IC`NCAITU.CF4VIOFtr <br />