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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEI SERVICES <br /> ENVIRONMENTAL HEALTH D IN <br /> P,O,BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 9520188 <br /> (209) 4883420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Kemple{In Trylk{i{) <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITTLE.CHAPTER 8-1110.3 AND THE STANDARDS OF SAN JO///A(1UIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDRESS/OR APNF ``� / It /��.� CITY A(((.-40 /LOTT SIZE/_&QJ�- <br /> OWNER'S NAME .(.C.1 L yy ��4�ADDRE66 t/djL+LC /+/ �"{� ,/ 7 PHONE�4,V///_7/((/2T() <br /> CONTRACTOR �)1 4 _ADDRESS/2-/ C- clLGGlc- l/ ?jT � 5' LICi 4122 R/0NE L{({.�) ) )� <br /> SUB CONTRACTOR ADDRESS LICE PHONE <br /> TYPE OF SEPTIC WDRK: NEW INSTALLATION❑ REPAIR/ADDITION D"TRUCTION❑ <br /> INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 2DO FEET OF BUIL INO.1 -C TESTI.1 1 I HOW MANY <br /> ��l�J APNlo�tlon <br /> INGTALLATION WILL SERVE: RESIDENCE LJ COMMERCIAL❑ OTHER❑ <br /> NUMBER OF LIVING UNITS: / NUM{ER-O/FJ,{EOIIOOMS: 3 Nwom OF EMPLOY'EEJ: <br /> CHEFATMENT <br /> OF SOIL TO A DEPTH OF 3 FEET: )41 - PT/SUMP SOIL CHARACTER:G WATER TABLE DEPTH <br /> EOREA6E TRAP ❑TYPE/MFG CAPACIT' NO.COMPARTMENTS <br /> PUNT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEMI <br /> \ S' <br /> LEACHLINE NE ]�'NO,i LENGTH OF LINER�-C1Q � �/lQ- DISTANCE TO NEARE BT:WELL LT`r FOUNDATION�0 PROPERTY UNE <br /> FILTER{ED /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FDUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH r7 LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> Ly <br /> SEEPAGE PIT{ DEPTH C I 612E ��O'1 NUMBER DISTANCE TO NEAREST:WELL��FOUNDATION PROPERTY UNE /-S <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I HEREaONA <br /> T 1 HAVE PREPARED THIS APPLICATION AND TH HE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND RIONSTHE SAN JOAOUINCOVNTV.HOME OWNEROR E ED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'ICERTIFVTHAT INTHE PERFORMANCE OF THE WORK FORVJI/ICH _A <br /> THIS PI SHALL NO Y ANY PERSON IN SUCH MA ER A8 TO BECOME SUBJECT TO WORCMAN'8 COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR <br /> SUB-CIy <br /> IES T FOLLOWIN :' CERT TMA IN THE PERFO CE OF THE WOFW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TOWORKF CALIF RNIA.' THE NT MUS CALL 24 HOURS IN ADVANCE FO/RALL MQUIRED INSPECTIONS. COMPLETE DRAWINO BELLOW.SIGNETITLE: l.t/�l.% DATE: (v Z� �✓ ///`'''�l��I <br /> PLOT PUN(DRAW TO SCALEI SCALE1. NAME9 OF ST PE ETSRE6T TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM 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 AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> \-rA <br /> FOR DEPARTMENT USE LY <br /> APPLICATION ACCEPTED BY_ �{- ONDATE: <br /> �� dd AREA: <br /> TANK,PIT OR BUMP INSPECTION BY DATE / ( FINAL INSPECTION BY DATE <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY AID! FAC/ <br /> PE CODE FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE {R/PERMIT NUMSER INVOICE 7 <br /> 52.10 /!5 !eo °?' `ill7 6v (2 7Z D3a8 <br />