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APPLICATION FOR LIQUID WASTE PERMIT <br /> %I w4 JOAQUIN COUNTY PUBLIC HEALTH ameRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICBmplel6 In TrlpFealml <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRICT ANDIOR INSTALL THE WORK DESCRIBED, THIS APPLICATION 19 MADE IN COMPLIANCE WITH BAN <br /> JOA[lU1N COUNTY DEVELOPMENT TITLE.CHAPTER Il-1110.3.AND THE STANDARDS OFF SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRE68VOR APNN (rj U�99 /r/,' j WOO yr ,6 A JP 6j f 6�/L_G��J j ',` y��p CITY , � c7A t�/�'1-e-_j --/Lot BI�Z-Er y�� <br /> OWNER'S NAME A AT)N /v. L A L ` ADORES. Z V/{/I / /L^• rr r/UI�,IJ t ,)Y✓.e !T Y PHONE 3 b9' /7:!� <br /> CONTRACTOR ADDRESS " L1Cs PHONE <br /> SUB CONTRACTOR ADDRESS IVLIC# PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ <br /> RIO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIQ 1 1 HOW MANY <br /> Appk&dDn IF <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF LMNa UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYM: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPI TANXiaRtASE TRAP 13 TYPEIMFO CAPACITY NO,COMPARTMENTS <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> y UFT STATION❑ 612E TYPE OF PIMP SAND OIL SEPARATOR!ENCLOSED BYSTEMI <br /> LEACHING UNE ❑ NO.A LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> stomps ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATIDN PROPERTY UNE <br /> DISPOSAL POMDS ❑WIDTH (LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <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 REGULATxms OF THE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIHEB THE FOLLOWING:'1 CEKTIFYTHAT IHTHE PEmF*MiIANCE OF THE WORK FOR WINCH <br /> THIS PERMIT IS ISSUED,I$HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFONIA.' CONTRACTOR'S HIRRM OR <br /> SUB-CONTRACTRRG OIGNATURE CERTIFR:B FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WH"THIS PEFMT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO <br /> y WC#$Cf8Awn CO PENSAT N LA OF 7HE APPLICANT MUST CALL 24 HOURS IN ADVANCE I"ALL REOU11M INSPBTIONS, COMPLETE DRAWINJGJ BELOW. / <br /> B_IO�N�EO`'7J(y TILE: ©, — DATE: <br /> ' PLOT PLAN IDMW TO SCALE)SCALE 'Ie <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF 14OUSE BEWAOE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. ExPANSION OF SEWAGE DISPOSAL$Y8TEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, i. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOBWNG PROPERTY, <br /> i. <br /> Z <br /> . <br /> 0 <br /> IF <br />