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APPLICATION FOR LIQUID WASTE PERMIT , w <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 988, SD4 EAST WEBER AVENUE, STOCKTON, CA SIMM- 88 <br /> (209) 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICompMu in Triplicate) <br /> APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMMANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAODU N COUNTY PUBLIC HEALTH/S�.ERVIICCES,ENVIRONMENTAL HEALTH DIVISION. <br /> l i _ N., e_� , .H /i-?_ CITY _L.4=� r» �'tl LOT SIZE --I <br /> .ROB ADDRESSIOR MMS - <br /> /(Py�H/OPZHNE <br /> OWNER'S NAMERADORERS <br /> !�/�J 7 <br /> ONE-=4;:Z <br /> CONTRACADORE <br /> BUB CONTRACTOR �'� __ADOREBF_. - <br /> I UDC`I PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RMAIAIADDTION ❑ DESTRUCTION ❑ <br /> MC TFATNI 1 1 HOW MANY `— <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN ZOO FEET OF BUILDINO.1 <br /> Appllostlan♦/I �[ l r <br /> INSTALLATION WILL BMW RESIDENCE❑ COMMFRCIAI. ❑ OTHER ❑_ p <br /> NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS:____ NIIMSER OF EMPOT'EES' <br /> CHARACTER OF SOIL 10 A DEPTH OF 3 FEET: RT/SUMP SOB.CHARACTER_ WATER TABLE DEPTH pJ_ <br /> SEPTIC TANKIMEASE TRAP ❑wmmFG CAPACITY,__ NO.COMPARTMENTS CIT <br /> PMO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL ___ FOUNDATION PROPERTY LINE _ <br /> UFT STATION❑ S1ZE TYPE OF PUMP -- SAND OIL SEPARATOR IENCLOSED SYSTEMI <br /> LLACIBNG UNE ❑ NO.S LENGTH OF LME@ 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 LINE <br /> SEEPAGE RTA ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> BUMPS ❑MOTH_LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTI'LINE f-1f1 <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH D@TANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(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 CEPTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICII <br /> THIS PERMIT 19 ISSUED,1 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 ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL N NOW IN ADVANCE FOR ALL REGYIRIED INSPECTIONS. COMPLETE OMWIM BELOW. <br /> SIGNED X' % '7. 7 TRLE: `-'/ L /L-/ i�{�hle.S'ATE: <br /> PLOT FUN(DRAW TO SCALER SCALE Z <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE POPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF TIRE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DEPOSAL SYSTEMS. <br /> .T. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND FPOPOSED 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. <br /> ' <br /> r � IL JI <br /> J <br /> a ,N <br /> 1115G <br /> j z +1 aUfi 1 3 `Ig9E <br /> we �� <br />