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joAPPLICATION FOR LIQUID WASTE PERMIT <br /> S. JOAQUIN COUNTY PUBLIC HEALTH S. .VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN/ ( Ci r�J r/1�,�%!>>q 1 (P CITY LOT SIZE <br /> OWNER'S NAME�L,!/a /2.r c i t�: !?!)/�- ADDRESS /C �!� i;,.�9 . ,7,i. +s�, PHONE <br /> CONTRACTOR /—�. cel,�% ADDRESS LIC(.—.�.��j ?r PHONE t:}_` ✓'1�� <br /> SUB CONTRACTOR ADDRESS LIC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTM I 1 HOW MANY <br /> Applimdon I <br /> INSTALLATION WILL SERVE: RESIDENCE]�( COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF LIVING UMTS:_ NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: ` PfT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> i <br /> SEPTIC TANK/GREASE TRAP ❑TYPE/MFG 141 L. CAPACITY /!7/%1.- NO.COMPARTMENTS <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL J C� -"T FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) _ <br /> /LEACHING UHE ❑ NO.k LENGTH OF UNE6 �— �— DISTANCE TO NEAREST:WELL ^'*/:)FOUNDATION C.°�PROPERTY UNE <br /> L' <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <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 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 f <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR 'tel <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> SIGNED X � `T �Z-L-[."L �^ DATE:- <br /> PLOT <br /> TITLE: �-cr7i y; .,w��Z"ati'-'�- DATE: ! <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 ld <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 STRUCTURES, 6. 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 /> `. ....:. . - ....i ` ....:.... .. .. <br /> _ tY' :�L r <br /> 1 <br /> . ....... .. .. <br /> � .. a <br /> ssA <br /> . ' <br /> a <br /> V) .. ... <br /> ...........V..... .... . ........ .... <br /> -t/ <br /> ,.- <br /> :... ................. <br /> .. ......... ;....1� <br /> .............. .................. <br /> :. <br /> :. .. ......... .. �T' <br /> �.. <br /> . <br /> l., ..... \ ...;...:.. J <br /> 111 <br /> . ... .. <br /> .. .... ..... ..... <br /> ... .. <br /> .._ ... . ._ , } SEP 17 1999 <br /> _. <br /> ... - <br /> .. II .... .'...... ..../ 'J ... ... 1 CtlNJt)J' 1111 ii- I�t <br /> Nvli <br /> FOR DEPAPTMENT USE ONLY DATE: r <br /> APPLICATION ACCEPTED BY - 1 —W `' AREA: <br /> TANK,PIT OR SUrr����--1tL1/p.INS.PECTIO14 By <br /> DATE / / FINAL INSPECTION BY GATE !Z <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AID1 FAC# <br /> ITE <br /> PE CODE PEE INFO AMOUNT REMITTED C /CASH RECENED BY DATE SR/PERMIT NUMBER INVOICE <br /> 0-5 <br /> Pub.Health Serv.-Enviro.174(3/96) <br />