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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES OV �� f <br /> F! ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> I NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> ! {Complete in TripReatel <br /> APPLICATION LS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. TWO APPLICATION IB MADE IN COMPLIANCE WITH BAN <br /> JOAWW COUNTY DEVELOPMENT <br /> TTT-I LE.CHAPTER 9.111 10.3 AND THE STANDARDS OF'SAN JOAOUN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> f� JOB ADDRESS/GR A1.1 NR I ! d �r A:!- 1'L ��e --_ --- CIIY��L-l'�l t'/%./ LOT SIZE <br /> OWNER'S NAME, �J/►�J�IIf � <br /> CONTRACTOR �N C F ADORESB IZO�U J. J!'�'J�Ghr _i✓�L. _L/ F410NE <br /> �Yf.'..�FJ PL�l�-C ADDRESS •1�-� ��I �l�'' _ Y_Y P4lONE �'CTZZ <br /> E <br /> "SUBCONTRACTOR ADDRESS LIC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPARVADDITION AFJLTRUCTtON❑ <br /> t F IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF Bum"NO.) PERC TESTIQ I 1 NOW MANY <br /> ]� APpae�Ben r <br /> INSTALLATION WILL SERVE: RESIDENCE IBJ COMMERCIAL❑ OTHER❑ <br /> NUMBER OF LIVING UNITS:3 NUMBER OF BEDROOM,: 3 NUMBER OF EMPLOYFEY:F <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITIb P X CHAIVICTER: jWATER TABLE DEPTH <br /> ,ERIC TMEKIGREASE TRAP TYPE/MFG�An/CI—C'� - _CAPACII_(2OO (N�- - NO-COMPARTMENTE <br /> PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> k€ LIFT STATION❑ SIZE TYPE OT PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM{ <br />€ LEACHING LINE ❑ NO.A LENGTH OF LINES DISTANCE TO NEAFREST:WELL FOUNDATION - PROPERTY UNE <br /> FILTER BED ❑VNDTH LENGTH DEPTH DISTANCE TO NEAREST-WELL FOUNDATION PROPERTY UNE <br /> 1rMOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEEPAGE PTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DUMPS C]WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL r-OUMOATWN PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LIVE D <br /> FAND1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK RILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY GROIIANCEB AND STATE LAWS,AND RULES <br /> REOVLATIONsOFTHESAMJOAOMNCOUNTY.HOMEOWNERORUCENSIEDAGENT'SSIiNATURECERTIFIESTHEFOLLOING.1CERTIFYTHATINTHEPER140MANCEOFTHEWOFKFORYWICH <br /> Il THIS PERMIT to tOOVED.I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME bUWECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S WING OR <br /> SUB.CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:I CERTIFY THAT N THE PERFORMANCE OF THE WOW POR WHICH TMb PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br />} ,WORKMAN'S COMPENSATION W8 OF CAUFOR►IA.' T APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RQDURED INSPECTIONO. COMPLETE DRAWING BELOW. <br /> 6 J <br /> - TITLE: 1 �9d s � V,�v DATE: �� v <br /> SIGNED x <br /> 3 PLOT PLAN(DRAW TO SCALER SCALE_, 'Ie <br /> �I 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYBTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOIRNG PROPERTY. <br /> _ - - .. I <br /> .. .....P � � <br /> ............................... <br /> .......... <br /> .................. ........... ...... ...... ............... <br /> y <br /> SHIV.L)A6Ult�u �� <br /> PUBLIC Ml:A1,i H DN!4tON .. . <br /> E3JVIF\QF1IA {TIk1-'4M' <br /> . <br /> ......_ ....: <br /> . <br /> (rf Z(� .. <br /> ............. <br /> . .............................. ...... <br /> ............... <br /> ................ .. ..... <br /> ............ ........... <br /> ............ <br /> ... � <br />