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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAGUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PA BOX 38% 304 EAST WEBER AVENUE, STOCKTON, CA 9.5201388 <br /> (209) 488.3420 <br /> I <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � <br /> ' (Complain in Triplicatal <br /> APPLICATION IS HEREBY MADE TO THE SAN.IOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN ! <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.)ENVIRONMENTAL HEALTH DIVISION. <br /> .JOB ADDRESSR OAPNR...-y 9,3 Cfl-y— LOT SI)C/ <br /> �j® <br /> OWNER'S NAME Y ADDRESS � (�_T � PHONE �✓� <br /> CONTRACTOR ADDRESS � —UC9 PHONE /0 � <br /> SUR CONTRACTOR T_ ,ADDRESS_—_" jej <br /> � LIC! PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REP/JRIAgOIT10N ❑ gE67RI/CTION ❑ <br /> [NO SEPTIC SYSTEM PERMITTED IF PUSLIC.SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(e)I 1 HOW MANY <br /> " Appllne8un 6_— <br /> IN6TALLATION W!L!.RFRVT: i!ESIf]EfICaI ❑ C:C1Mti1EF{L:lRL U OTHER ❑ � r- <br /> NIINIRER OF I.IVIN(1 1104 fA: ...__ Nl"p(n Of AFi1R(e m,pA. 1 OF rmpt,OYFFw /�• <br /> CHARACTER Or SOIL'1O A DF.I!TI1 OF JFF[r: _ _ FITISUMP nOIL CHARACTER: WATER TARLE DEPY]I Cv <br /> SEPTIC TANKOIREATL TRAP El TYPEIMFI;� � —� - CAPACFT"Y� NO.COMPARTMENTS rL <br /> PKG TREATMENT PLANT ❑ D14TANCE TO NEAAEST; WELLFOUNDATION I'ftOPERTY LINE v <br /> LIFT STATION© TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) <br /> SIZE c <br /> LEACHING UNE NO.a LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION`PROPERTY LINE �a <br /> flLTER BED C3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIOTHLENGTH DEPTH'�'�`DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> SEEPAGE q ©DEPTH �J—SIZE _ NUMBER / DISTANCE TO NEAREST:WELL FOUNDATION _PROPERTY LINE <br /> BUMPS ❑WIDTH LENGTH DEPTH DISTANCE 70 NEAREST:WELL FOUNDATION PROPERTY LINE Zi <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES�� Y <br /> ANDREGULATIONO OF THE SAN JOAQUIN COUNTY.140ME OWNEROR LICENSED AGENT-S SIGNATURE CERTIFIES THEFOLLOWING�"lCERTIFYTHATINTHEPERFORMANCEOFTHEWOPKFORWHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENVATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR G <br /> SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS BUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGWACD INSPECTIONS, COMPLETE DRAWING BELOW. <br /> SIGNED X /— <br /> "�LI 7tTLE: DATE: L� I �✓ <br /> PI.OT PLAN(D[[[RAW TO SCALE)SCALE •to L <br /> 1. NAMES Or STREETS OR ROADS NEAREST TO OR BOUNDING TIfE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> J_, OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPORED STRUCTURE$, S. LOCATION OF WELLS VNTHIN RADIUS OF ONE HUNDRED FIFTY FT,ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY, <br /> ... . .. . ... ._ .. ...,., i .fir] <br /> 1 <br /> #.0 <br /> FOR DEPARTMENT USE ONLY <br /> AM'LICATION ACCEPTED BY - DATE; AREA; <br /> TANK,PIT OR SUMP INSPECTION BY - DATE___l ! FINAL INSPECTION BY pATEZO <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AIDA FAC/ <br /> PE CODE FEE INFO AMOUNT REMITTED CHECK RlCASH RECEIVED BY DATE SR!PERMIT NUMBER INVOICE t <br /> DIC„_ „_ 3�vv <br />