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A(CATION FOR LIQUID WASTE PERMIT <br /> a— SAN'JOAQUIN COUNTY PUBLIC EALTN SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 3K 304 EAST WESERA Ne CA 9MI <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> OmPkts I11 Tripik®t®1 <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTAL,THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TIT ,CcHAPT�ER,9a-11110.3�AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH®SERVICES,ENVIRONMENTAL HEALTH DIVISION.kuA110 a <br /> JOB ADDAESS/OR APNB pS®(1�L1, ° .eNi`%,�'�17A v W f y✓ ®CITY {/� j- LOT SIZE d <br /> OWNER'S NAME MR } t'tW! Kp ft i LTi Ks`��{ y ADDRESS J,@I I 1 G1vT J PHONE "534 <br /> r 13,ICV �p <br /> CONTRACTOR MLVO N D.Y JG r 1I%V AODRESB .°'Bl`, L �G UCN / 23 913 PHONE 3I"'P�CR r <br /> SUB CONTRACTOR ADDRESS 5TW�® 5 t)�' LRC# PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDI: DESTRUCTION ❑ <br /> @IO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING. TESTI.1 I I PROW MANY <br /> p,,�/ 1 0(f�S APPBwtlon# <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL Fel OTHER❑ RQ� �W� <br /> NUMBER OF LIVING UNITS:_ NUMBER OF 86DROOMS: NUMBER OF EMPLO � <br /> CHARACTER OF SOIL TO A DEPTH OFF 3{FEET: LO 1"'*. GGPITIsUryMP SOIL CHARACTER: —WATER TABLE DEPTH y <br /> SEPTIC TANK/OREASE TRAP 19TYPE/MFo WNy.L*.. r" �"' CAPACITY Ibov Af,110 W NO.COMPARTMENTS 6r <br /> PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL ®9� FOV ATION_'S j-- PROPERTY UNE <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM( <br /> LEACHING UNE ❑ NO.A LENGTHOF LINES DISTANCE TO NEAREST:WELL ® FOUNDATION PROPERTY UNE <br /> FILTER BED WIDTH r LENGTH '7 p DEPPN t DISTANCE TO NEAREST:WELL /ST! I�FOVNDATON�PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEWAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> S ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS : ❑WIOTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT!HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOME 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:'1 CERTIFY THAT IN THE ROMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> SU"ONTRACTING 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 /> WO MAN'S COMPENSATION LAWS OF CALIFORNIA.': THE APPLICANT MUST CALL 24 IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. y <br /> NEDx Cl®�"� TITLE: I'"' DATE: � <br /> PLOT PUN(DRAW TO SCALEI SCALE TTT <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 />,2s;`PENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUC S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> ELUDING COVERED AREAS BUCN AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR G PROPERTY. <br /> .. .. ... <br /> gIG .... <br /> ..:::.:.. . <br /> .....:.. ... :....-...... .. <br /> �a .... PAYMENT <br /> PA4 1998 <br /> � q <br /> - . <br /> 4Fj J <br /> UB G1 f:CS <br /> r1ENi' t IiCA!�Tpi�NIs^14rv; <br /> ....:.. <br /> : <br /> :...... ......:......:. ..................... <br /> . } ` <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 1 DATE: AREA: <br /> TANK,PIT OR BUMP INSPECTION BY DATE / FINAL INSPECTION BY DATE <br /> ADDITIONAL COMMENTS: A) <br /> n t C'y <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODE FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE OR/ T NLS INVOICE# <br />