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PLICATION FOR LIQUID WASTE PERMIT <br /> ;r EALTH SERVICES r <br /> SAKI JOAOUIN COUNTY PUBLIC H <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED' <br /> (Complete IR TripReatel <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT'ANWOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAH <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9- 110.3 ANJO-THE ST,A-Nl[DJARD&OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. L.� <br /> (� BIZ GI/i W7� Z CRY zyL LOTSRE�/ <br /> JOS ADDRESSIOR APNr <br /> DINNER'S NAME <br /> ^�y {!�E AbDRE$$ OI� [r I ` P►IONE <br /> ,t" � ADQRESS � v/�LICf PHONE <br /> CONTRACTOR 1 <br /> BUB CONTRACTOR <br /> 1' ADDRE$$ r� LICE���PHONE <br /> ' TYPE OF SEPTIC WORK: <br /> NEW INSTALLATION REPAIRIADDITION ❑ :- D ON❑ / <br /> INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF SUILDINO.I <br /> _ PERC 7ESTU1 L f NOW MANY <br /> . APPeatl°n I <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL OTHER❑ <br /> NUMBER OF WINO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES-. <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITJSUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANKIGREASE TRAP ❑TYPEIMFO CAPACITY NO.COMPARTMEMS <br /> PKO TREATMENT PLANT❑' DISTANCE TO NEARFAT: WELLFOUNDATION PROPf�Y uKE <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACIeNtl LINE ❑ NO.a LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL <br /> FOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL. FOUNDATION PROPERTY LINE <br /> SEWAGE PITS ❑DEPTH eRE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SUMPS 13 WIDTH LENGTH _ DEFTH DISTANCE TO NEAREST:WELLFOUNDATKIH PIgpEPf7Y LINE <br /> I� <br /> DISPOSAL PONDS �WtDTI LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> 1 HERESY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONe OF THE DAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEIrORMANCE of THE WORK FOR WISCH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'@ HIRING OR <br /> SUB-CON'TRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE-PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'@ CO NSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL M HOURS IN ADVANCE FOR ALL REDURED IINB�P/ECTIONS. COMmm OMVNNO BELOW. <br /> SIGNED x <br /> TITLE: r rr r,D ►iCr^T _ _DATE: 7 <br /> If <br /> ff PLOT PLAN IDRAW TO SCALE)SCALE_ Ic <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <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 /> _... .................... .. -.._ . ....,......___.......,.,... _ .. _ ., .. - --- <br /> _- <br /> r- <br /> —0011111111 <br /> ............ ... ..... .. .. .r.. ....... ......,... ,.. _,.-...J...... : .. ... <br /> ---. . .... 1 ... -- ... - ' --, - ...... .. <br />{ ... ?A.RKI'M <br /> ( <br /> ..:..... <br /> xlsru <br /> ..., ... ..., - . ... ..... ........: .. `` ........�LD�;: ...... .. ... ...... .. 7 �� ;.. . ..... <br /> �. Ti2yCK PARXl�tG <br /> ....... I [ <br /> .............................................. ................. ... J <br /> .2GolA?19N. <br /> f .. <br /> ... _ � � <br /> .. <br /> - I.rEv.. <br /> T�-A .cs Yy : . <br /> N.D. USS ... .... FEB:.2 <br /> _ " S .. SA JUAOUIN C0 T <br /> *NVIFIONMENTAAt H£Al TF1 <br /> FO11 D T USE ONLY y/} <br /> APPLICATION ACCEPTED BY - DATE: J�f —AREA: <br /> TANK.PTT OR SUMP INSPECTION BY DATE 1 !-- FINAL INSPECTION BY ATE ! I QU <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AID# FAC,# <br /> PE CODE FEE INFO AMOUNT RUAITED Mitt ASH FIECOVED BY DATE SR I PERMIT SIMMER �] INVOICE f <br /> i' . CJ <br /> Pub.Health Serv.-Errviro.174(3196) <br />