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} APPLICATION FOR LIQUID WASTE PERMIT /! l <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES / / c <br /> ENVIRONMENTAL HEALTH DIVISION l <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 \ --- <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Comple(s in Triplicate) <br /> Application is hereby made to the San Joaquin County for a permit to construct and/or install the work described. Th11s application <br /> is made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County,IPublic Health <br /> Services, Environmental Health Division [ <br /> Job Address/or APN# V . City Lot Size <br /> Owner's Name Address Phon�qu <br /> Contractor �- 1 Address Lic#� ; ,3 C d Phgnb <br /> Sub Contractor '— Address Lic# _ Phone_____ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION 1 I DESTRUCTION I I PERC TEST(s)I 1 How many <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEN R IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> land Use App ieation r <br /> Installation will serve: Residence Comnerci Other or 6 a S� <br /> Number of living units:t Number of bedrooma: Nunber of employees: <br /> Character of soli to a dopth of 3 feet: P1[/Sump SolI haracter: Nater Table Depth_ <br /> SEPTIC TANKIOREASE TRAP [I Type/Mfg Capacity No. Compartments <br /> PKO TREATMENT PLANT [ ] Distance to nearest: Well .l 0� /t/ Foundation b Property line--J�1� T <br /> LIFT STATION[] ze Ty a of Pump! _ Sand Oil Separato (enclosed syst . ) <br /> LEACHING LINE No. & length of line Distance to Nearest: We[( oundation- Property Line S <br /> ILTER BED Width Length Depth_ " Well Foundation Property Line <br /> F <br /> MOUNDED [I Width Length Depth Well Fopndation Property Line <br /> SEEPAGE PITSI� Depth2 Size Numbe g� " Well oundation Property Line <br /> SUMPS [I Width Length Depth Well Foundation Property Line <br /> DISPOSAL PONDS [] Width Length Depth Well Foundation Property Line <br /> I hereby certify that I have prepared this application and that thewor --tp t be done :ir).accordance with San Joaquin County Ordinances <br /> and Siete Laws, and Rules and Regulations of the Sen Joaquin Go N lowt4e ojx-gicensed agent's signature certifies the following <br /> - employ Y <br /> • "1 certifythat in the performance of the work for which thi r�jt s 1 :sitalL not to an person in such a manner as <br /> to become subject to workman's compensation laws of Californiq"",' �A a"etoh'' �Irfng or sub-contracting signature certifies the <br /> following: "I certify that in the performance of the work` oF' ieh-. iiL it i?8 i's` fa�d, 1 shall employ persons subject to workman's <br /> compensation laws of California.', <br /> The applicant mutt c 1 24 [ours In ■dvAnts for all required inspections. Complete dr pK09q)t!6.014! <br /> ',115 - I Iii l( l it r l ' I e <br /> Signed X l' L JZG"Z. 1 ' Li f m I',}. }1 Lli1'tlem�'�jt(,(/ltl L Date / <br /> PLOT PL (Draw to Scale) Scale " to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage 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 and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, drivew s, the property r adjoining property. <br /> m and walks. <br /> r <br /> c!f <br /> FOR DEPARTMENT USE 11 Y <br /> Application Accepted by L 43� Date: h-�trea:. <br /> Tank, t\ or Sure Inspection by✓ � �+>4 Date �Finat Inspection by _ �� Datef�/.1 /i <br /> Additional Comments: <br /> ACCDUNTIN I ONLY: AID# FAC# <br /> PE CODE FEE INFO AM,RUNT REMITTED CHECi'�l'ICASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE # <br />