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k <br /> APPLICATION FOR LIQUID WASTE P' <br /> SAN JOAOUIN COUNTY PUBLIC HEALTHES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 368, 446 N. SAN JOADUiN ST., STOCKTON, CA 95201.0388 <br />'I (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRDN! DATE ISSUED <br /> (Complets'la Triplicate) <br /> Application is hereby made to the San Joaquin County::for a permit to construct and/or install the work described. This application <br /> is made in compliance with San Joaquin County DevL-Lnpment Title, Chapter 4-1110.3 and the Standards of an Joaquin County Public Heatth <br /> Services, Envirormentat,Health Division. <br /> J <br /> Job'Address/or APN# f City Lot Size <br /> Owner's Name A ess Ph <br /> r 3J <br /> Contractor!( Address J Li hon <br /> Sub Contractor Address <br /> & Lic# Phone <br /> TYPE OF SEPTIC WDRK: NEW INSTALLATION I I REPAIRIADDITION E 1 D STRUCTION[(I"' PERC TESTY)E I Now man; <br /> (NO'SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 20 EET OF ILDING.) <br /> La tiApplication <br /> Installation will serve: Residence Commercial a Other <br /> Number of living unita:-I Number of bedroomrt I Number o employeest <br /> character of soil to a depth of 3 faet: tf Pit/Sump Soil Cha cter: at a Depth <br /> SEPTIC TANKIOREASETRAP `; p Type/Mfg r a actp- Coag menta <br /> ,y <br /> PKO TREATMENT PLANT [ ] Distance to nearest: Well ound n lin <br /> LIFT STATIONS) Size Type of Pump: send Oil Separator (enclosed system) <br /> LEACHING LME [] No. & length of lines it Distance to Nearest: Well Foundation Property L { <br /> FILTER BED [] Width Length Depth '',!' " Well Foundation Property Line <br /> MOUNDED [] Width Length Depth " to Welt Foundation Property Line <br /> SEEPAGE PIT$ [] Depth Size Number �I " Well Foundation Property Line <br /> S <br /> SUMPS [] Width Length Depth r " !' Well Foundation Property Line <br /> DISPOSAL PONDS [] Width Length Depth " Welt Foundation Property Line <br /> ,p <br /> I hereby certify that 1'have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances <br /> and State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the fotlowing <br /> "I certify that in the performance of the work foriwhich this permit is issued, I shall not employ any person in such a manner as <br /> to become subject to workman's compensation laws ofjCalifornia." Contractor's hiring or sub-contracting signature certifies the <br /> following: "I certify that i the performance of the work for which this permit is issued, I shall employ persons subject to workman's <br /> compensatio taws of Cat rnia." <br /> The appliaaat t all 24 r is adw or all iaqulrad iaepeetionr. Gomplete drawing below, <br /> Signed X TitIe:.ji:P6 V�`�" Dater '�` r <br /> - <br /> PL PLAN (Dr'a'w to Scale) Scale " to <br /> .i <br /> 1. -Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. :Outline of.the property, with dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. ;Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such aX' . <br /> 's, driveways, , the roperty or adjoining property. <br /> snd walks. <br /> �h <br /> 17 <br /> W4. <br /> f� <br /> i <br /> I� <br /> d� <br /> :...Ww- - :- �"":` "nr:..:-+ o <br />