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APPLICATION FOR LIQUID WASTE PERMIT <br />•r --- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />v �� DIVISION <br />ENVIRONMENTAL HEALTH TOCKTON, CA 25201.0386 V��l�l�''D <br />P.O. BOX 388, 446 N. SAN JOAQUIN ST, <br />L(91 (209) 468.3420 <br />NON REFUNDABLE PERMIT E3IPIREII 1 YEAR FROM DATE ISSUED lication <br />(ComplMa IN YfIFFN 41 <br />Application is hereby made to the Sen Joaquin County for a permit to construct and/or�install the work doaquiin oun y public Health <br />is made in corrplience with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of Sen Joaquin `L A�� g <br />services, Envirormental Health Division- City L� Lot Size <br />3 y E . PLAY CA ----------- <br />Job Address/or APN# '4,70I/ F Ekc�NW�M Z(, L1Nr) 9ri236 Phone <br />D -L r r ��mgvt ___ Address �Y Phono423'Z(?_/ <br />Owner's Name F—� GjQ'D p /YV E _Lic# — — <br />Sle6l 4EA E6141t4EtjgInIFT Address! <br />Contractor Lic#`___ Pho <br />Address <br />Sub Contractor DESTRUCTION I I PERC TEST(.) IKNaw ea <br />REPAIpJADDITION l 1 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 Land Use Applicatlem # <br />(NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br />Commercial! other_ 1 <br />Installation will serve: Residence_ NumWr of amploYeut G R <br />Nurl>•r of Ilving untun Number of Mdroaman,_. PitlSumP Solt Character:_,,,-- Water Table Dapth______..a� <br />Character of soil to ■ depth of 3 featr,,.�_._--- CepacitY.No. Compartment• <br />SEPTIC TANNIOREABE TRAP 11 Type/Mfg Property line <br />Foundation <br />PKO TREATMENT PLANT I ] Distance to nearest: Well (enclosed system) Send oil Separator <br />LIFT STATION ❑ SizeType of Pulp _ <br />Distance to Nearest: Well Foundation nty <br />LEACHING LIME 11 No. &length of lines Property Lipro rt <br />FILTER DED j)Width Length_— Depth <br />u �� Well Fwatdetion Property Line <br />MOUNDED 11 Width Length ' De <br />Yell Foundation Property Line <br />SEEPAGE PITS U Depth_. Size N r ^ <br />Well Foundation Property Line <br />p�s�pr���•'6t'"� ]I It Foundation Property Line <br />NOVT <br />[1 Width`_ Length_ Det `�di9i1� <br />w ( undation Property Line <br />L PONDS 11 Width Length_, DWI I mit may ha NB <br />DWI <br />accordance with Sen Joaquin County Ordinance <br />y certify that 1 have prepared th{s apple��¢t�t�ton a a€(}j{Qr w gte Leus, end Rules and Regulations of ihe^Sanf;�i�t C2 tyN/ j+�Cn or ti %aleu agent's aigny pe certifies the fallowingrtify that in the perforntence of the work for j r�ryqi is ss( sj� e�ll not employ any peraon in such a manner eaa! ',4'db°ar subcontracting signature certifies th <br />ome subject to workman's compensation leas of Celifornie." CpbtpUing: "1 certify that in the performance of the work for which this pe t ���i(;5��}�, i shell employ persons subjoct to workmen'ation laws of California." V/�kaat moat gA1�24 boon Ie advaaea for all nq�uCka�d I//a'spwtbae. Cortplete drawing below. f �'��—~ Title: —Date- K <br />PLOT PLAN (Draw to Scale) Scale " to <br />1. Names of streets or roads nearest to or bonding the property. 4. Location of house sewage disposal system or <br />2. outline ofthe property, With dimensions and North direction. proposed OKpansion of sewage disposal systems. <br />3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. or <br />structures, including covered areas such as patios, driveways, the property or adjoining property. <br />and walks. - <br />a <br />Application Accepted by <br />Tank, Pit or Sump Inspection <br />( <br />Additional Comments: <br />Area: ___Z-1-�_ <br />