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APPLICATION FOR LIOUIQ WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,446 N.SAN JOAQUIN ST., STOCKTON,CA 96201-113BB <br /> (209)460.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Ttipkets) <br /> Application is hereby made to the San Joaquin County for a permit to construct and/or install the work described. This application <br /> pm <br /> is made in compliance with San Joaquin County Develoent Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> J <br /> Job Addresai or APNN /pQrd T�� /n�y�� city i Lot site <br /> Owner's Name-,?,V _2 0,n.-/✓_ Address :510zn , LL �/�/// ' _Phone <br /> Contractor ��1 �� _Address )^W4 !1/ lLiPlrlatr22>a LIcM - rte _Phone L63 s— 7 <br /> C- Sub Contractor Address tick Phone <br /> \�\(0��.'� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAUUADDITIOMA DESTRUCTION[I PERC TES7NI(I How me V <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> )SIJ (n1 LLand Use A'plkadam I <br /> Installation will serve: Residence Commercial_ Other' yk[ ��S uC, tiE'I)I1PI� <br /> uaber of living unite� Number of bedroom I Number of employees: !,J <br /> heracter of soli to ■ depth of 3 feet: PIt/Sump Soft Character: water Table Depth <br /> TP. <br /> EPTIC TANXIOREASE TRAP I Ty mr/Mfg�/v �j�/L Capacity (JCJ No. Coopartments <br /> KG TREATMENT PUNT ( 1 Distann+. to nearest: well Foundation Property line e <br /> LIFT STATION O Size_ Type of Pump Sand OiL Separator (enclosed system) <br /> LEACHING UNE 1Q No. & Length of Lines -- Distance to Nearest: Well-ILL FotrtdatIcn 4 / Property Linty.4C , <br /> ILTER BED O Width Length__Depth " " WeLI_ Foundation Property Line <br /> MOUNDED 0 Width Length__Depth " "' Veli Foundation Property Line <br /> SEEPAGE PITS j[ IIepth � Sixa�r, Number_ liell_J_�_ Foundation IM Property Line s0 <br /> SUMPS 11 Width Length Depth well Foundation Property Line <br /> DISPOSAL PONDS O Width Length Depth " " Well Foundation Property Line <br /> OI hereby certify that 1 have prepared this application end that the work will be done in accordance with Sen Joaquin County Ordinances <br /> and State Laws, and Rules and Regulatlons of the San Joaquin County. Home;aver or licensed agent's signature certifies the foLL owing <br /> f� : "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such a manner as <br /> to become subject to workmen's compensation laws of Colifornia." Contractcrts hiring or sub-contracting signature certifies the <br /> following: "1 certify that in the performance of the work for which this permit is issued, 1 shell employ persons subject to workman's <br /> compensation laws of California.$' <br /> The appReeat must sag 24 hours In dear,for all required Inspections. Uvptste drawing below. <br /> Sigrid X Title: riry Date: <br /> PLOT PLAN (Draw to Scale) Scale " to ��// CC�"� <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sew"Ip9ReNy/tem or <br /> 2. Outline ofthe property, with dimensions and North direction. proposed expansion ofp��a�w rim stem <br /> 3. Dfawnsioned outlines and location of a([ existing and proposed 5. Location of wells wit el¢T ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoiry{TNrptm ,194 <br /> and walks. I(11 lOO JJ ��1 <br /> IN C0 NTY <br /> sJJ 0 72V <br /> X <br /> w <br /> r , <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �}�i 'J J l Date: t_Aree: Z <br /> Tank, Pir Sump Inspection by TOC",[/�Date/,?//-'£lnal lnspeciian by �,�y-Jf _Date(/ <br /> Additional Comments: <br /> ACCOUNTINO ONLY: AIDN FAC# <br /> (PIE CODE FEE INFO AMOUNT REMITTED CHECK SH RECEIVED BY DATE I SN 1 PERMIT NU INVOICE# <br /> Y <br />