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APPLICATION FOR LIQUID WASTE PERMIT <br /> St.14 JOAOUIN COUNTY PUBLIC HEALTH 'AcRVICES <br /> ENVIRONMENTAL HEALTH DIVISION �A <br /> ' 304 EAST.WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 OY <br /> D •REFUNDABLE ERM P RES 1 YEAR FROM DATISSUED `t <br /> lComplats In Triplkatsl <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AMIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE PITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRTLE.CHAPTER 8-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br />[ - JOB ADDRESSOR APN# <br /> 7 CITY /� LOT SIZE <br /> E PHONE <br /> t OWNER'S NAME { �••✓ ADDRESS <br /> CONTRACTOR <br /> ADDRESS ,..! //.' LIC! l 4 RHONE <br /> SUB CONTRACTOR ADDRESS LICK PHONE <br /> TYPE OF SEPTIC WORN: NEW INSTALLATION I8 REPAIRIADDITION ❑ DESTRUCTION D <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.I FERC TESTdN 1 1 HOW MANY <br /> Ap*mtlon# <br /> INSTALLATION WILL SERVE: RESIDENCE 13 COMMERCIAL 0 OTHER❑ <br /> NUMBER OF LINO UNITS: NUMBER OF BEDROOM!: NUMBER OF EMPLOYEE!: e <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP;SOIL CHARACTER' r "WATER TABLE DEFT <br /> IJ <br /> 40MC TANGUOREASE TRAP OTYPEUMFO C [ CAPACITY -20-2.0 NO.COMPARTMENTS <br /> PKG TREATMENT PLANT© INSTANCE TO NEAREST: WELL, FOUNDATION PROPERTY UNE <br /> UFT STATION© SIZE TYPE OF FUUMMP SAND OR SEPARATOR(ENCLOSED SYSTEM( Ir <br /> LEACHING LINE III NO.S LENGTH OF LINES Q — I DISTANCE TO NEAREST:WELA�,±FOUNDATION PROPERTY UNE <br /> FILTER SW ❑WIDTH LENGTH DEPTH DISTANCE JO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED 13 WIDTH_LENGTH_DEPTH DISTANCE TO NEAREST:WELL FOUNDATION� PROPERTY LINE <br /> ' <br /> SEEPAGE FITS ��,.��SIZE- —j=NUMBER��DISTANCE TO NEAREST:WELL FOUNDATION � _PROPERTY LINE ` rn <br /> SUMP! 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DNSPGSAL.FONDS O WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT 1 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 REGULATION!OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FORWIBCH <br /> T1410 PERMIT IS 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-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COM7 LAWS OF CAUFORHIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING/BELOW. <br /> SIGNED% TRLE:_l-1 �N �� `DATE:, / s <br /> I <br /> PLOT PLAN(DRAW TO SCALE)SCALE 'to <br /> 1. NAMES OF STREET!OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. - 4. LOCATION OF HOUSE SEWAOE DISPOSAL SYSTEM OR PROPOSED <br /> I 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. - EXPANSION OF SEWAGE DISPOSAL SYSTEMS. - <br /> "ME WONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN MINUS OF ONE 14UNDRRED FIFTY FT.ON <br /> ./ INCLUDING COVERED AREAS SUCH AS PATIOSF DRIVEWAYS,AND WALKS. <br /> .. THE PROPERTY 09 <br /> NO PROPERTY <br /> w ....... <br /> . . . <br /> . . - <br /> u r Y ...... ` Vit, K. <br /> ... �.n ..... .... <br /> .. <br /> .. .......: ....:.... <br /> ...:......:......; <br /> Q .Q .............................. <br /> ... . :. ......,..r. . -....;..........._ .......... ......................� ............................................J�. <br /> ?csfD <br /> { <br /> 00: . 1— , <br /> t-.. .,...`.......:.... :....`7. L......,..... PUBL] HEALTfIECiVI ,.. V <br /> ENVIRO <br /> !.. .. .. ...... .. <br /> t s <br /> I <br /> 3 ... ,..,..A.,. L�.�... . <br /> - .....: ......:.:..... :...... ..... ...` ..... <br /> :... ..... <br /> -_c.L............... ....... <br /> OEPARTMErIr USE ONLY <br /> c9- <br /> k APPLICATION ACCEPTED BY r DATE: <br /> TANK.PIT OR SUMP INSPECTIOO114 <br /> /BY DATE FINAL INSPECTIOrY <br /> 1 ADDITIONAL COMMENTS: `.1 u- N ol / <br /> o0wl <br /> */w <br /> I ACCOUNTING ONLY: MDI' FAC# <br /> PE CODE 2-15V <br /> FEE INFO AMOUNT(R�UAITER IEC CASH RECEIVED BY DATE SR!PERMIT NUMSL#1 INVOICE# <br /> Ir 5 v`...!`.' . <br /> Pub.Health Serv.-Envlro,174 0M) <br />