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APPLICATION FOR LEDUID WASRNIIT <br /> SAN JOAOUIN COUNTY PUBLIC HE, SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.D.BOX 388,445 N.SAN JOAOUiN ST.,STOCKTON,CA 56201-0388 <br /> 12091468-3420 <br /> - RON-REFUNDAO[E PERMIT EXPIRES 1 YFAR FROM OAT ISSUED <br /> (Camplsb i Tiiplkatel <br /> Application is hereby mode to the San Joaquin County for a permit to construe[ and/or install the Mork described. This application <br /> is made in compliance with son Joaquin county Devetopment Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health <br /> Services, Enviro mentai Health Division- <br /> 1 .lob Address/or APN11 K City t-aC-F-P�t-��-� Lot Size <br /> Owner's Mane � l/v ti1C-VFX/ Address LiD43 Phone�Q7 <br /> i <br /> Contractor (off_ � �j(' _ Address { Phone.'3L,R_ .'{�i3i' <br /> Sib Contractor Address Lic;1 Phone - <br />' TYPE OF SEPTIC WOR%: NEW INSTALLATION I I REPAJRfADDITI011 DESTRUCTION(I PERC TESTIQ l I Haw ramal <br /> f (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SELLER 15 AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> Land Uw Application I <br /> installation will serve: Residence_ Co mercialV- other_ <br /> _ Nuabor of living units:_ Nun>er of bedrooms;_ Nunbor of aeployme.: <br /> * �2 <br /> character of soft to a depth of 3 feet: CbPit/Supp Solt Character: )�- Water Table Depth^ <br /> SEPTIC TANIUOREASE TRAP 11 Type/Mfg Capacity Mo. Compartment■ <br /> - PX4 TREATMENT PLANT I ) Distance to nearest: Well Foundation Property LLne <br /> LIFT STATIONLI Sjze Type Of'Punp Sand Oil Separator (enclosed system) <br /> LEACHING LINE Pf No. R length of tinesC/)S ' Distance to Nearest: Well_k<nl Foundation?A' Property Litr.,,<j� �y� <br /> FILTER BED a Width Length Depth " " Well Foundation Property Line 3� <br /> iI MOUNDED [7 Width Length Depth " " Well Foundation Property Line Qi <br /> r <br /> - SEEPAGE PITS M- Depth fize34o" Number -0, M " Well Foundation_--_' L Property Line S-� <br /> SU NPS L1 Width Length Depth " WelE foundation Property Line <br /> DISPOSAL PONDS IT Width Length Depth " Well Foundation Property Line <br /> I hereby certify that I have prepared this application and that the work Mil[ be done in accordance with San Joaquin County Ordinances <br /> aid State Laws, and Rules and Regulations of the San Joaquin County. None owner or tiemsed agent's signature certifies the followin <br /> "1 certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such a manner a°,v' <br /> to became subject to workmen's compensation laws of California-- contractor's hiring or stab-contracting signature certifies th,3. <br /> following: "1 certify that in the performance of the work for which this permit is issued, I shat[ employ persons subject to workman' <br /> -- compensation laws of California.' �.q <br /> 76 applicant oust a4N 2 uua in adraama aR n ohad intpsctimas. Complete drawing below. <br /> F <br /> Signed X /LIJ LIT/'I/ Tlt(e: nY][7Z Date- l,�'�`'`7Lj <br /> � PLOT PLAN (Draw to Scale) Scale to �� <br /> - 1. Nerves of streets or roads nearest to or bonding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of.the property, with dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 1 3_ oimensiuxed outlines and location of all existing and proposed 5-- Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> aid walks. <br /> I tn A #4 <br /> 3: _i;1tS4 Gni-N Y <br /> J FOR DEPARTMENT USE ONLY <br /> { <br /> App iication Accepted by c, Date: Z� <br /> [^ Tank, &or Supp Inspection by atej al Inspection by-,-- <br /> Additional <br /> y Additional Comaents• <br /> AFLDUNTINO oNtY; AIDS FACO <br /> t <br /> PE CODE FEE INFO AMOUNT REMIiiED E ,pCASR RECEIVED BY DATE SR J PERMIT NUMBER. INVOICE J <br /> f 1 r1 <br /> f � <br />