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APPLICATION FOR LIQUID WASTE PERMIT <br /> ro SAN JOAQUIN COUNTY 40LIC HEALTH SERVICES <br /> SAN JDAQT.'T�ICGLTNTI'-p �. tT �ENTAI HEALTH DIVISION <br /> £�;- ,•,,,.,,ti,,�..rAT b�ic' ea„ JOAQUIN ST,STOCKTON,CA 95201-0388 <br /> 1 77 Y. <br /> (2091 4112.3420 <br /> aVlt�lEf IDABLE PERMIT EXPIRFs I YEAR FROM DATE ISSUED <br /> ico-wiata in Tjonbl <br /> Application is hereby made to the San Joaquin County foro permit o corstruct and/or Install the work described. This application <br /> is made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public health <br /> Services, Environmental Health Diviei <br /> Job Addreaai or AP N Ci Lot Size q r/ <br /> Owner's N Address <br /> �y <br /> Contract Address f LicN7 ( Phong7r-Y-.S /os <br /> Sub Contractor Address Lich Phone <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION[i REPAIAiAODITIONAt DESTRUCTION I I PERC TEST MI I I Hess merry <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> Lar Use A/plisatioa <br /> Installation will serve: Residence Co morcial_ Other_ <br /> Number of living / <br /> unitsl� Murber o} edrog t Number of aaployaaa: <br /> Character of moll to • depth gf 7 fe*'�PiI/Sump Sail Character: _Water Table Depth_ <br /> SEPTIC TANKIBREASE TRAP ❑ Type/Mfg -[%2:9 _ _-_Cepeclty_ No. Comportment. <br /> PRO TREATMENT PLANT ( J Distance to nearest: Well Foundation _ Property line <br /> LIFT STATION[] Size_ Type of Pump Send OIL Separator (enclosed system) <br /> j' LFACHIMO UNE Q No. A length of Linea Distance to Nearest: YellFoundation Property Lin- <br /> FILTENBED [I Width length__Depth " well Foundation Property Line <br /> MOUNDED [1 Width Length_ Depth a " Welt Foundation Property Line <br /> \ SEEPAGE PITS Deptt,�L5 Sixe_�16 NunberJ_ ° " k;ell/0d f Foundation/O f Property Line v <br /> sumps p width Length Depth Wait Foundation Property Line <br /> DISPOSAL PONDS [1 width Length Dep'h Wall FounciatIon_Property Line <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordant*with San Joaquin County Ordinances <br /> and State Laws, and Rules and Regulations of the San Joaquin County. Now owner or Licensed ag*nt'a signature certifies the following <br /> . "1 certify that in the performance of the work for which this permit is issued, 1 shall not *rnptay any person in such a manner as <br /> to become subject to workman's compensation taws of California." Crntractor's hiring or sub-contracting signature certifies the <br /> following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's <br /> compensation t ws of California." <br /> The applbam must L 74 baro Is s a g I.4wbod laap.olieme. Ccmpleta drawing below. 7/ �J <br /> Signed X - - Title: �, Date:17ed <br /> PLOT PLAN (Draw to Scale) Scale " to <br /> 1. Nam*s 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 systaes. <br /> 3. Olmensloned outlines and location of ell existing and proposed 5. Location of wella within radius of 150 ft, on <br /> structures, including covered areae such as patios, driveways, the property Fr adjoining property. <br /> end walks. , <br /> D <br /> IV U <br /> 1_ <br /> I <br /> _I <br /> F VI'ES <br /> NVIR NM tNTA HEA TND <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b <br /> FP P Y Area: Z <br /> Tank, or Sump inspection by w Date FiTnaL Inspection b r�--C v -Zalfi 74, <br /> Additivonal Comments: <br /> ACCOUNTING ONLY: AID# FAC# 0 — <br /> PE CODE FEE INFO AMOUNT REMfTTEO E C11SH RECEIVED BY UATE SR I PERMIT NUMBER INVOICE/A <br /> !� ` f <br />