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APPLICATION FOR LIQUID WASTE PERMIT <br />SAN JOA(IUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201.0388 <br />1209) 468.3420 <br />DN-REFUNDARIE PERMIT EX RES J YEAH FAOM DATE ISJUED <br />(Daphne in Trirliesta) <br />App(Ication is hereby made to the Son Joaquin Co�nity for- a perinit Cu corisirttct nn /ci install the isark described. Thie app(fc©tion <br />is made in compliance with Son Joaquin County DeveloWnt Ittle, Chapter 4-1110.3 mini the Standards of Joaquin Couray Public Health <br />Services, Environmental Health Division, r <br />A <br />Job Address/or APH Cit Lot Size <br />r�Owner's Now L Address <br />ontractor, n Address f ' LicN�LL Ph 5...fr'�iJ <br />Sub Contractor Address Lie# Phone ��• <br />TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION I I DESTRUCTION I l FERC TE9.rw I I Now sue; <br />(NO SEPTIC SYSTEM PERM11TED IF PUBLIC SERER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br />Land Uma APPModen I <br />Installation will serve: Rasidence !�f Comer Other. <br />Number of living unitmi-1— Number of bedroom Number of septoyesal <br />Character of soli to a depth of 3 feet' A P t/Sump Soil C oracterr hater Table Depth-- <br />SEPTIC <br />epth <br />SEPTIC TANKIOREASE TRAP 11 Type/mIg � � .t Capacity Na. Compartments <br />PIIS TREATMENT PLANT I ) Distance to nearest: Welt 1i Foundatt-1 Property line <br />LIFT STATION ❑- e Type of Pura_ send oil Separator (anclosed system) <br />LEACHING LINE No. i length of line Distance to Nearest: Well &eundation� Property Lira <br />FILTER RED 11 Width Length" Depth " Well, Foundation Property Line <br />4�MOUNDED 0 Width ! Length r_ Depth Well Foundation �,_ a,Property Lina <br />YEEPARE IMT! 0 Depth Size ^ Nus+be " " dell CFaundatlon---7— °roperty Like <br />SUMPS [I Width Length Depth " " Well Foundation Property Lire <br />DISPOSAL PONDS 11 Width Length Depth " " Well Foundation Property Line <br />1 hereby certify that 1 have prepared this applicatiai and that the work will be done in accordance with San Joaquin County Ordinances <br />and State laws, and Rules and Regulations of the San Joaquin County. Hone owner or licensed agent's signature Certifies the following <br />: "1 certify that in the perforamme of the work for wfafch this permit is Issued, I shall not employ any person in such a manner as <br />to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies the <br />following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workmwn's <br />compensatfon law of California 11The 1"Seat nowt 3S 24 imers ( ala for all ragekee Inweetism. Cocaplate• drawing batow. <br />Signed <br />PLOTIPLAN (Draw to $cele) Scale " <br />I. Names of streets or roads nearest to or bounding the property. <br />2. Outline of the property, with dimensions and North direction. <br />3. Dimensioned outlines and location of all existing and proposed <br />structures, including covered areas such ss ptioe, drive�+ys, <br />and walks. �'1 ? J / _ �{! _ <br />l <br />Title:/(.(<4%Aff— Dete'J o'er/ -%y <br />to <br />4. Location of house sewage disposal system or <br />proposed expansion of ystams. <br />(� 5. Location of wile uitrg 1 0 ft, on <br />the property or adjoi" z+t� <br />