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APPLICA FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209) 468 3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complala in Trglkata) <br /> •°PLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPIJANCE WITH SAN <br /> AOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> �BADDRESS/OR A�jP1NI (f�Jrl� ��S I QICCZ.I C �© Fi- CITYC.--(,� ROT 6/1Z/E-7 � <br /> OWNER'S NAME (!l'G E��- ��C��-/'L//�L ADDRESS `PHONE 9.5i-75' ( 7 <br /> 'NTRACTOR `-//e /�r ADDRESS/,'/ J/ � L• /✓�"'�7' 57�-LIC/ •Y Y�Z PHONE CCI'3 5 7 7 J J <br /> B CONTRACTOR ADDRESS LIC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADNTIO DESTRUCTION Cl <br /> I SEPTIC SYSTEM PERMT ED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF ILDIN6.1 PERC TESTIO I 1 HOW MANY <br /> ApplI..tI D 0 <br /> „�:TALUTION WILL 6EAVE: RE BIDENCE COMMERCIAL❑ OTHER Cl <br /> NUMBER OF LIVING UNITE:_:N Bpi OF BEDROOOMS:_NUMBER OF EMPLOYER: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: G�tU PIT/SUMP SOIL CHARACTER:�06C 6� WATER TABLE DEPJz TH / r-e- <br /> PTIC TANK/OREASE TRAP ❑TYPEIMFG CAPACITY NO.COMPARTMENTS <br /> _O TREATMENT PLANT Cl DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE V'I <br /> UFT STATION❑�-S�IZEI TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI t, <br /> LEACHING UNE 0.6 LENGTH OF LINER 7� l r/r DISTANCE TO NEAREST:WELLL [�FOUNDATION PROPERTY LINE <br /> TER BED //❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE .1 <br /> IUNDED \�❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> �EEEPAGE PITS �1 DEPTH Z SIZENUMBER CY DISTANCE TO NEAREST:WELLG�FOUNDATION 7C) PHOPEMY LINE 5�/ <br /> SUMPS /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE V <br /> n <br /> ,POSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE r- ,Q <br /> EREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THA THE WOW WILL BE DONE IN ACCORDANCE W TH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULESRULE9\r\• <br /> LTJ D REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER ORLI BED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFYTHAT INTHE PERFORMANCE OFTHEWOPK FORWHICH <br /> THIS PERM C N(.LL NO PLOY ANV PERSON IN HUGH M NEft AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR O <br /> SUB-C S NAT E IE HE FOLLFY TH IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> T MA�RACTING <br /> 'S COMPEN TION W F CA IFORNIA.' T ANT MUS 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. (\C� <br /> ,NED% TITLE: �I7>^L !�C DATE: <br /> \` PLOT PUN IDRAW TO SCALE)SCALE •le <br /> NAMES OF STREET OR RO EAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 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 On ADJOINING PROPERTY. <br /> 44 <br /> 3rv�r,t2y"` �/f S <br /> f 2 33 IT <br /> i o <br /> / FOR DEPARTMENT USE ONLY <br /> -5PLICATION ACCEPTED By — DATE:0 AREA: <br /> TANK,®r OR SUMP INSPECTION BV <br /> DATE /��LjNAL INSPECTION BY ATE <br /> )DITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AID/ FACS <br /> PE CODE FEE INFO AMOUNT REMITTED CHE //CASH RECEIVED BY DATE SR I PERMIT NUMBER O�L <br /> t 5 l ' �flz:L�- <br />