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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 /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complltl In Tripliaat/) <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 BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF 8 JOAQUIN CO NTY PUBLIC HEALTH SERVICES. <br /> EN NMENTAL HEALTH DIVISION. <br /> 7 <br /> JOB ADDRESS/OR APNI / S50 -z/ ��G1�--��/J CLOT SIZE <br /> OWNER'S NAME✓��/�C�� �`/� e1 `�" ADDRESS -_PHONE_�`y1/A <br /> CONTRACTOR_ /" `V'i'i ��K / ADDRESS 12-1 ��✓"~U'I �I C� Sr ZO l Lc, Y'I, Z LyPHONE <br /> SUB CONTRACTOR ADDRESS LIC# PHONE <br /> TYPE OF SEPTIC WORN: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ <br /> ING SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW 1 1 HOW MANY <br /> Appll -do.0 <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF LPANG UMTS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: ` <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET �IF AAPITISUMP SOIL CHARACTER-1�1L TJ WATER TABLE DEPTH <br /> T C T NK/OREASE TRAP ❑TYPE/MF 1'�'IC. c L CAPACITY co C>CD COMPARTMENTS <br /> PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE l 00 <br /> LIFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I <br /> LEACHING UNE �NO.a LENGTH OF UNES 3-e 10, ��•n.4z DISTANCE TO NEAREST:WELL_FOUNDATION PROPERTY LINE <br /> FILTER BED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> SEEPAGE PITS 5"EPTH ate-, SIZE T� NUMBER 3 DISTANCE TO NEAREST:WELL( <::::V FOUNDAT/ON/OG PROPERTY LINE 00 <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AN THAT THE WOPK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND FiEOUTA OF THE JOA COUNTY.HOME OWNER LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT INTHE PERFORMANCE OF THE WORK FUR WHICH <br /> THIS PERM 1818 ED,1 AL EMR- ANY PERSON M A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOIWIA.' CONTRACTOR'S HIRING OR <br /> SUB-CO RACTINO A IES T FOLLOWING: , RTI THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKM N'8 COM T CAU IA.' T UST CALL 24 HOURS IN ADVANCE FOR ALL jE^G,UP INSPECTIONS. COMPLETE DRAWING BELOW. \ <br /> SIGNED TITLE: 1"�' DATE: ( D- 7- <br /> PLOT PLAN(DRAW TO SCALE)SCALE_ •tc \\\� <br /> 1. NAMES OF STREETS OR ROADS NEAR O OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 13 <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 WALKS- THE PROPERTY OR ADJOINING PROPERTY. <br /> - i ._J._. ... .. ...! ..... - <br /> Lto <br /> ........:.. . <br /> .. . <br /> ...:. <br /> Nod ° . .�.' �.1.{.s ; ` <br /> . -.. 1 ..;. <br /> V ... ... ... ' r' ^ <br /> COT' <br /> 44x <br /> �J N Vt <br /> .D <br /> h...... ........... .... <br /> cllp F. <br /> )JIB r <br /> �IVVtr1�)NIiIFH�lr n�C xt 1 <br /> -jell • .... l h <br /> .....:..... <br /> 9T <br />