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APPLICATION FOR LIQUID WASTE PERMIT <br /> AN'JOAQUIN COUNTY PUBLIC HEALTH SERVICtj <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95.201 88 f 6) 'S--4/90 <br /> (209) 488.3420 _ <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS PF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> U-3 y �, �, t UX ( Ole" <br /> JOB ADDRESS/OR APN# � `-� jj_ I C.z�.L) /�L CITY �i/LiC�'/ .�� LOT SIZE' <br /> u& <br /> NAME C Aj SC �l ADDRESS PHONE <br /> CONTRACTOR a-� � ,4`�- -�`� ADDRESS c LIC# PHONE <br /> ,ems lr ,, . '7t �' <br /> SUB CONTRACTOR i �_ (.,'r'�/ ADDRES CA-' { (l� y�-� UC# .� PHONE--�`Lj� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION ❑ DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(s)I I HOW MANY <br /> may-- APPlloe e n <br /> INSTALLATION WILL SERVE: RESIDENCE OS- QMMERCIAL OTHER ❑ <br /> NUMBER OF LIVING UNITS:_ NUMBER OF SEDROOMS� NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: .;�� /'' 1-/'`�PIT/SUMP SOIL CHARACTER: MM//,, WATER TABLE DEPTH <br /> SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY 000 NO.COMPARTMENTS <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OFPUMP_�� SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING LINE gi NO,t LENGTH OF LINES.18 9 33 2 DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTH 70 DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SEEPAGE MTS DEPTH ICJ SIZE_NUMBER_DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT I 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 REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSU HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA,' CONTRACTOR'S HIRING OR <br /> SUB-CONTRACT( SIGNA RE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'SMPENSATI Vy8 /OF ALIFORNIS. THE APPUCAN ST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS. COMPLETE DRAWING BELLOW. <br /> SIGNED X �1/JV. TITLE: DATE: / � Cl/ <br /> ✓ PLOT PLAN(DRAW TO SCALE)SCALE v 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STAUCTUREB, E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY, <br /> . ......... .. . . <br /> C ..r <br /> . <br /> ....'. : 4..... ... .. .. .. <br /> +.. <br /> .. . .. <br /> . .. . .. . <br /> . . .. <br /> YIE� .. .. <br /> Ecol � .................: <br /> .. .......: .. ...... .. NJOUIN COUPY.PUELTC HEALTH SERVICES ... <br /> J � � �' !.. ENVIRONMENTAL HEALTH DIVISION <br /> ... ... ..... .. <br /> SAN JQAUUI! : . .. .. <br /> . �P�Gl�4�._P�R�IAi'T' .. <br /> PURIC HFr`IT <br /> FNVIROW"I', ..,, 1 ,I..i ;... .. ... ...:........... .. .. ........................ .. <br /> I/ FnP t—APTI"ENT U15 OWY <br /> APPLICATION ACCEPTED BY DATE: / AREA: rrx'�/ <br /> TANK,PIT OR SUMP INSPE I B DATE / / FINAL INSPECTION BY DATES / /� ( o/ <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE FEE INFO AMOUNT REMITTED CHECK#/ ABH RECEIVED BY DAT $A/PERMIT NUMBER INVOICE# <br /> '-�l ll S 430 59 i3 u <br />