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APPLICATION FOR LIQUID WASTE PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 385, 445 N. SAN JOAOUIN ST., STOCKTON, CA 56201.0388 <br />1209] 485.3420 <br />NON-REFUNDAILE PERMIT EXPIRE! I YEAR FRDY DATE 11t0E0 <br />ICompleu Y TrifGats) <br />Appllcadon is hereby made to the San Joaquin County for a permit to construct and/or install the work described. This application <br />is mode in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of Joerpin Canty Public Health <br />Services, Environmental Health Division. r <br />Job Addresslor/A�PNA Cit Lot Siu <br />Owner's Meme L Address r3 <br />r <br />ontra�f i 1,I� <br />ctor Address / LicM, Ph -f♦� <br />Sub Contractor Address Lich Phone <br />TYPE OF IEPT)C WORK: NEW INSTALLATION NEPAIRIADDITIDN l I DESTRUCTION 1 I FERC in rbl 11 New -aaY <br />(NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 15 AVAILABLE WITHIN 200 FEET OF BUILDING.) <br />Lam1 UM AppSaaUsa P <br />installation will serve: Residence V C7rcf;N,— other, <br />Number of living uniter- Number of L. r000+i/a`�LJT-Number of saployuat <br />Character of moll to a depth of 3 festa P t/Sump S�o,1•l �C¢■rattan Lstar Table Depth <br />BEPTICTANKIOREASETRAP 11 TyFA/Nfg ��r4d A Capacity IJ V No. Corpartnent■ <br />PKO TREATMENT PUNT [ ) Distance to nearest: Well NU }1� Foundatfon Property If <br />Cid LIFT STATION[] a Typa of Pup Sand Oil Separator (enclosed system) <br />LEACHING LINE Mo. A length of linea_ Distance to Nearest: Well CFeurdation-16-1 Property Lim 4-14 <br />FILTER RED 11 Width Length" Depth Well Foundation Property Line <br />MOUNDED l] Width length Depth " Well foundation Property Lina <br />r s <br />SEEPABE PITT Depth 53ze Nuebe " WeIIWDytFourdstlmroperty Line <br />SUMPS [1 Width Length_ Depth wWell foundation Property Line <br />DISPOSAL PONDS 1] Width Lmpth_ Depth Well Foundation Property Lina <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances <br />X and State Laws, and Rules and Regulations of the San Joaquin Canty. None owner or licensed agent's signature certifies the following <br />"i certify that in the performance of the work for which this permit is issued, I shslt not employ any person in such a namer as <br />to become subject to workmen's conpeneation laws of Caiffornia.11 Contractor's hiring or sub -contracting signature certifies the <br />following: "T certify that in the performance of the work for which this permit is issued, 1 shall employ persona subject to workman's <br />compensatfon new of California 11 <br />The appEaaat aur Y 24 Maus=Azjg�j <br />llregak4 Nerpaadra:a. Cplete drawing below.)Signed X Title:A-64/itK. Date:/ V <br />PLOT 4LAN (Drew to Scsle) Scale to <br />1. Names of streets or roads nearest to or borrdin2 the property. 4. Location of house sewage disposal system or <br />2. Outline of the property, with dimensions and North direction. proposed exprwsion ofyetena. <br />3. Dimensioned outlines and location of sit existing and proposed 5. Location of walla wit0 1 0 ft. on <br />atructures, including covered areas such ms patiox, drlZv* ys, r the property or ad) oiFW. IMMQ <br />and walks. �'j ? J / wJ <br />G G1 f�L nrT i B X494 <br />L,• 14 <br />FOR DEPARTMENT USE ONLY r <br />Applicat n ACV-pted by S Date: re : <br />Tank, Pit or Sump inspection by Date / 1 Final Inspection ate%(37l <br />Additional Comments: <br />ACCOUNTING ONLY: I AID/ I FACY 11 <br />PE CODE FEE INFO AMOUNT RIMMED CASH RECEIVED By DATE SN PERMIT NUMBER INVOICE / <br />52o nom 4�Fb 9 <br />