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I <br /> i <br /> k APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 386,446 N.SAN JOAQUIN ST.,STOCKTON.CA 96201-0388 <br /> (209)4581420 <br /> NON REFURDABLE PERMIT EXPIRES 1 YEAR FROM OATS ISSUED <br /> rAmpista In TriplicaW <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 coapLiance 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 APN# 3149E Collier Road 005-040-56 CityA� Lot size 2 @3.18ACre <br /> owner's Nan_ V_ Pegs H <br /> a <br /> ffner _ Address )3149 E Collier Road Acanyo Phone 369-6150 <br /> contractor T- 1 1`T m��r0��1_Address Y'46/ Lich 6-916 Phone�63-k)77 <br /> Sub Contractor Address Lic/ phone�T <br /> TYPE OF SEPTIC WORK: MEW INSTALLATION(I REPAIRIAOOTINN I I DESTRUCTION I I PERC TEST{e) w aux <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> (SOIL SUITABII,=Y STUDY ONLY AT THIS TIME) PERK TESTS FOR la.l cess Agylfutbm a <br /> Installation will serve: Rasidence_ Cosxwrcial_ Other_ PAPOM j%P, ll h Q le's �f Alt <br /> Number of llving unites_ Number of bedrooms_ Number of enploysee: I y-3,- <br /> character of soil to a depth of 3 feet: Plt/Sump Soil Character: Nater Table Depth <br /> SEPTIC TAMKNINEASETRAP 13 Type/Nit Capacity_ No, Compertuent8 <br /> _--- <br /> 1� <br /> PKO TREATMENT PLANT I 1 Distance to nearest: well Foundation _ Property line 1 <br /> --t-- <br /> LIFT STATION[) Size_ Type of Pump Sand Oil Separator (enclosed system) <br /> LEACHING LINE U No. 8 length of linea Distance to Nearest: Wall__ Foundation Property Line <br /> FILTER RED (1 Width Length­Depth • " Well_ Foundation Property Line <br /> MOUNDED (1 Width Length__Depth • Wel! foundation Property line <br /> SEEPAGE PITS (1 Depth Size Nueber " Well Foundation Property Line O <br /> SUMPS (I Width Length Depth Wall Foundation Property Line - <br /> DISPOSAL PONOS 0 Width Length Depth • ^ Well Foundation Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Canty Ordirencuis <br /> and State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following <br /> •1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such a mercer asSZ <br /> to become subject to wortmen's caxpensation laws of c4lifornia." Contractor's hiring or subcontracting signature certifies the . <br /> following: •I certify that in the performance of the work for which this permit is issued, I shad sepioy Parsons subject to workmars'a <br /> caapensation laws of California.• <br /> The applitant asst call 24 Yawn In aKeuw for al nyek"11""tion. Complete drawing below. <br /> Signed X `1✓f ►+ Title:Date:-9-2-?!V <br /> /,. <br /> OT PLAN (Draw to Scale) Scale <br /> mm <br /> 1. Nas of streets or roods nearerr bounding the property. 4. Location of house aewage 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 anti proposed 5. Location of wells within radius of 150 ft. an <br /> structures, including covered areas such as patios, driveways, the property or adJolning property. <br /> and walks. <br /> , <br /> ` ` I <br /> a o <br /> FOR DEPARTMENT USE ONLY <br /> I�— <br /> Application Accepted by \ Datr. <br /> Tank, Pit or Sump inspection Uy Date / / Final Inspection Data <br /> Additional t;ctments- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE FEE INFO AMOUNT REMITTED CHECK11CARH RECEIVED RY I DATE $R I PERMIT MU <br /> L41-3 <br />