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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compkto In Triplka(s) <br /> APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPUANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE. <br /> CHAPTER 8-111/00'')3 AND THE BTA�IDARDB OF BAN JDAOUIfI COUNTY PUBLIC HEALTH SERVICES,�ENNVIIR�OONNMENTAL HEALTH DIVISION. <br /> JOB ADDREBS/O/R/A�}PN/(,�/ �7 li`�/ C.. 1..��J(/((// ,' /'C/-J7�x// CRY �C"�-/'�0 L jLO�Tj SIZE <br /> OWNER'S NAM1C6f,4—) �jl��'G��G�GLP-iL ADDRESS./�f_7. -3/��G�/C�//L1C.G"t` ,/Q/,Ctp�l7 �� ��� ('P14ONE J�!(U✓ ,7y/�J I`- <br /> CONTRACTOR � !/tet- �- ADDRESS/z(L' Cf']GGt L�GI,r!/�T' t. Y S7DUCf ��J PHONE <br /> vy <br /> SUB CONTRACTOR ADDRESS UC# PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBUC SEWER 18 AVA)ABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIS)I 1 HOW MANY <br /> AppB—don <br /> INSTALLATION WILL SERVE: RESIDENCE I�KCOMMERCIAL 11OTHER 11 <br /> NUMBER OF UVING UNITS:1_ NUMBER OT■EDROOMS: NUMBER OF EMPLOYEES: <br /> /C4/R��,j�ER OF SOIL TO A DEPTH OF J L PITlSVMP SOIL Ca1ARACTE /_ WATER TABLE DEPTH <br /> VL�PTIC T/tFIK/ORFJ►SE TRAP ❑TYPE/MFO (-11 '1�-Q -SLS'' :r.,CAPACITY (C.C..L�L� NO.COMPARTMENTS r <br /> PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL �(�C=� FOUNDATION PROPERTY UNE <br /> LIFT STATION❑ SIZE TYPE OF PUMP_SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> �J / <br /> LEACHING LINE may'NE l]f NO.6 LENGTH OF LINES NEB -- Z2�� DISTANCE TO NEAREST!WELL/00/ FOUNDATION l0 PROPERTY UNE <br /> FILTER BED /❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTHDEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE_ <br /> SEEPAGE ATS IOEPTH :�2 S ?, SIZE 4L- �r NUMBER_ DISTANCE TO NEAREST:WELL/S0 FOUNDATION-5b / PROPERTY UNE�Q <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGV NB OF THE SAN JOAQUIN COUNTY.HOMED ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:')CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PE IS SU LL EMPLOY ANY PERSO SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> SUB-CO RACTI O ON URE E FIES THE FOLLOWIN : ' CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORK AN'S CO SA WB ALI T CALL 24 HOURS IN ADVANCE FOR <br /> (/ALL <br /> REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. �}q7 <br /> SIGNS(X TITLE: --f��� DATE: /✓ _ <br /> PLOT PUN IDRAW TO SCALE)SCALE_ 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEM8. <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 /> ...... ......i..............................,.....(......i.............:.......j.....;.............. ... .. .. / .. <br /> :.......:......` ...,..... <br /> .................... . .. <br /> .....<.... ......;. ..............; .. ... . .. <br /> .. ... <br /> . ..... <br /> ..<... <br /> ......:..... < ... <br /> : : <br /> .. <br /> .......:...... : ; . ...... . <br /> ............. ..:.. . <br /> .................. : ... :............ . ..... .......:.... ...... <br /> : ......:..... . ............. ...... ...... <br /> .. ...;.. ..:... ....... <br /> .. .. .. .............. <br /> . <br /> .................................... <br /> ....... <br /> ...............:....................;......:... <br /> ....:................... <br /> ......>........... ................. . .. .. <br /> : . `. <br /> : <br /> ... .............................. . ..,......... <br /> ........................ ........................... ..... ...........: ... >..........>.... :..... <br /> :.....:......:..... <br /> ............:..... : ...... . <br /> .:........... <br /> ....... ....................... _ ..... <br /> ....................>.............. . . . ... . <br /> _ .. .. .. .......... .......................:.. <br /> ............ 0 <br /> ......... .... <br /> .... ..... ........:.......:............... I <br /> ........................ ..... ... . :.... ............'..... ... .......:.,.� ,.. .. . 1...� g ...... <br /> ,� ... .. pCT <br /> ..................... ...... N E S <br /> :.....:.. .... .. NMI- <br /> . E N-T <br /> . .. .... <br /> ...... .............>�j(o....? hS.. : . .. NV�RO � R�1C.E <br /> fir...:........ M �, <br /> ....................;......:................. . _........µ' :. ........... ....... ...;.......... PERM ;.... <br /> ....:.. ..:.....:. ....... <br /> . . . _ • C�� .. . .. . . '7 ' <br /> FOR ARTMENT USE ONLY /p <br /> A71CATION ACCEPTED BY - DATE: - U � v AREA:��a <br /> 1i �^ <br /> A OR BUMP INSPECTION BV DATE7�FINAL INSPECTION BY "! DATE '/ <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODE FEE INFO I AMOUNT REMIITED CIIEC CASH RECEIVED BY DATE SR/PERMIT NUM� BER INVOICE# <br /> � 3sl to ► �� <br /> Zc? <br /> Pub.Health Serv.•Enviro.174(3/96) �_ � ��^^ ���� �Ian ,, U1 !!-nI/�, <br />