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APPLICATION FOR LIQUID WASTE PERMIT <br /> .� SAN JOAQUIN COUNTY PUBLIC HEALTH SER,,:S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 <br /> (209) 468.3420 <br /> NDN-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete is Triplieata) <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 Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APNN �,s� <br /> City Lei Lot Size <br /> l� <br /> Owner's N ddress A t+� [comic S Z Ld Phone�J—� � <br /> Contractor 4s�Jt�e T►{J Address U g �L �o Y 1 Lic* 7j2SZZ 6Phone34(r S I C$ <br /> Sub Contractor Address Liter Phone <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I IEPAI DDITION i I DESTRUCTION I 1 PERC TEST(e)1 I Now msa <br /> (NO-SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> Lii1 Use Applw4oa 1 <br /> Installation will serve: Residence-1- Commercial Other <br /> Number of living unitri—j_ Number of bedroomat Number of employees: <br /> Character of roil to i depth of 3 feat: Pit/sump Soil Character: Water Table Depth <br /> SEPTIC TANKIGREASE TRAP [] 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 (enclosed system) <br /> LEACHING LINE .144 No. & length of lines — 4cKDistance to Nearest: Well IL6-19Foundation_W11Property Lira <br /> FILTER RED [) Width Length Depth " IN Well Foundation Property Line <br /> MOUNDED [] Width Length Depth " " Weil Foundation Property Line <br /> SEE De / Number �, r�datian—Property Lir <br /> SUMPS () Widthl Length Depth_ " " We1 !' f Foundation Property Line <br /> y DISPOSAL PONDS Q 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 Ordinances <br /> and State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following <br /> "i certify that in the performance of the work for which this permit is issued, I shall not employ any person in such a manner asC <br /> to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies th <br /> following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman' <br /> compensation laws of California." 6 <br /> The applicant must call 24 houFss]Is rants far all required inspections. Complete drawing below. ' <br /> signed XTitle: - Date, 'Y <br /> PLOT PLAN (Draw to Scale) Scale Is to <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 S. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> L� <br /> t <br /> Ap <br /> iCJU4 CC,[ 'r <br /> LE tt—]I I I I t r H ALT SE V! <br /> .,, Vr ,a _ <br />