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APPLICATION FOR L10UID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.0388 <br /> 12091 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Kamplato in Triplieats) <br /> APPLICATION IB HERESY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANMR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COFAPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OFF SAN <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES,RMAONMENTAL HEALTH DIVISION. <br /> JOB ADORESSIOR AF #ac--o <br /> 7 Z.3 / S &-etq/_ _ ` 7 �j CrfY d p'T �1� LOT SIZE <br /> OWNER'S NAME (,p�`_ fl li-; - L ICL/ ADORE" Z�� /�� 3 y Z / PHONE <br /> CONTRACTOR / ADDRESS LICA PHONE <br /> SVB CONTRACTOR 411.4 �/�L- _ ADDPE88 /'{ �1LICI R1oNE�j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 RVAIWADDITION IV DESTRLK:TIONI❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF 8011.0R40) FERC TEATIO I I HOW MARY <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL IIp OTHER❑ <br /> NUMBER OF LIVING UNITS: NLANS9L OF BEDROOM$' NVIA601 OF EMPLOYEES: !S <br /> CHARACTER OF SOIL TO A DEPTH Of 3 FEET,-� Aft//TISUMP SOK.CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANKJQIEASE TRAP ❑TYPE/MFG 4-I+/ CAPAC fT\' �.- NO.COMPARTMENTS -Z <br /> PKO TREATMENT PLANT❑ ONSTANCE TO NEAREAT: WFLL��LF'�r­ FOUNDATION__./ T' PROPERTY LINE: r <br /> LIFT nOM Cl 3ta TYPE F PUMP <br /> NO � O i LENGTH OF LINES —'e"FT DISTANCE NEAREST:WELLS <br /> LEACHING LINEI&IZI) LMDATIONZ-,OW PR�RTY UNE��� <br /> i <br /> FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST-WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH_ LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE FITS ❑DEPTH S12E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION <br /> - PROPERTY UNE <br /> SUMS 17WRITH� LENGTH �-/ OCPfH /e 018TANCE TO NEAREST:WELL f o�FOUNOATK)N��r PEP1T`/UN£�l�fi' <br /> DISPOSAL PONOS ❑WADTH LENGTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> W <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 �I <br /> AND RE13ULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNFR OR LICENSFD AGFNT'S SIGNATURE CFRTIFIES THE FOLLOLMNG:'I CLARIFY THAT IN THE PFAFORM ANC E OF THE VJOIK FORWHICH <br /> TH18 PEMYT 19 ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WON(MAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S MNNG OA ^ <br /> SUB-COHTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TH£WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMP1 OY PERSONS SUBJECT TO �J <br /> WORKMAN'S COMPENSATION LLAWWSJS OOF CAUFORNIA.- THE A"UCANT MINT CALL 24 HOURS M ADVANCE FOR ALL REOLARED INSMT1ONs. COMPLETE DRAWING OEEELLLOOW. <br /> SIGNED X A7•/� a _TITLE: ./s/E �� OA7E: <br /> PLOT PLAN(DRAW TO SCALE)SCALE ' <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2 DLTTIINF Of THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL DL18TING AND PROPOSED STRUCTURES, S. 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 /> � 6 <br /> ' o P <br /> � sr <br /> �Ilk. .�, <br /> .� <br /> Or r t <br /> F� <br /> E----%..�:-�tla>� F h h J UN 2 4 1996 <br /> - - - — <br /> SAN <br /> Fl"fiLiC HEAr_.Th <br /> 'EAE, <br /> FOR DEPARTMENT AMIE ONLY - <br /> 7PL <br /> APICATION ACCEPTED BY DATE:----7AEEA�� <br /> TANK,PIT OR SUMP INSPECTION SY ATE / 7 FINAL INSPECTION BY ` DATE (a,; , f l(o <br />