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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (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 applica <br /> is made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Hei <br /> Services, Envirorvmental Health Division. �� / J / 16--2-2--7 <br /> Job Address/or APN# Z6!Z cam+ , /yam TLS tee,Lq T2. /7— <br /> � �J/+>C <br /> it �e,)'I Lot size <br /> E COwner's Name Address__�0 466A- 6C) 7 Pe <br /> ��Zam ?2-0 <br /> Contractor�// p-r >/� C/- Addressi� -0/L� 6 '/ <br /> Sub J <br /> Contractor Address Lic# Phone <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 11 DESTRUCTION I I \ PERCTESTIS)I How many <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) --- <br /> /,� land Use Application Y <br /> Installation will serve: Residence '� Commercial Other �y /I �fn�i`tQJ— <br /> Humber of living unite: Number of bedrooms: Number of enployess: - _ <br /> Character of soil to a depth of 3 feet: Pit/Sump Soil Character: Water Table Depth_ <br /> SEPTIC TANKIOREASE TRAP [I Type/Mfg Capacity No. Compartments_ <br /> PKG TREATMENT PLANT [ ) Distance to nearest: Well Foundation Property line <br /> LIFT STATION[] Size Type of Pump Sand Oil Separator (e oge em) <br /> � <br /> LEACHING LINE ❑ No. 8 length of lines Distance to Nearest: Well Fo ad iNpP�roperty ne <br /> Li <br /> FILTER BED (I Width Length Depth " " Well Foi laoperty Line <br /> MOUNDED ❑ Width Length Depth " Well �AFrq a�tibn"" '• %roperty Line <br /> V UA ('0 <br /> SEEPAGE PITS 0 Depth size Number Well FUBL.�ww o rty Line <br /> q�� i ' <br /> SUMPS [) Width Length Dep*.h - " " We(l C JRp U(h at�bn�tr'AI.TII Ifyi Fy Line <br /> DISPOSAL PONDS U Width Length Depth " Well Foundation Property Line <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinan <br /> and State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the follow <br /> : "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such a manner <br /> to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifies <br /> following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workma <br /> compensation laws of California." <br /> The applicant must <br /> call 24 hoursinadvance for all required inspections. Complete drawing below. �^ <br /> Signed fl1 ✓/V��tX TitKes < < Date: '30 <br /> PLOT PLAN (Draw to Scale) Scale " to_ ;��0 <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system o <br /> 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage disposal syste <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> r <br /> � ^ �vAY Rour <br /> : <br /> 4 PAr <br /> fmJ <br /> o H <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ,�-c Date: <br /> Tank, Pit or Sump Inspection by Date / / Final Inspection by Date�� <br /> Additional Comments: 2? �G �ncf� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE D <br /> z bolya�s <br />