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APPLICATION FOR LIQUID WASTE PERMIT 00160 7 <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 988, 304 EAST WEBER AVENUE, STOCKMN, CA 95201388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND <br /> /THE STANDARDS OF SAN JOA UIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APNN `7 / �? (r / i ](, 137 CITY . 4.x(,4. JI� LOT SIZE(w/� <br /> y�� `� T //� ry <br /> OWNER'S NAME -L ,( L^�i'ADDRESS 1.d�2c.1� PHONE�W / /({ e <br /> CONTRACTOR ADDRESS 12-1 - Y1- PHONE <br /> SUB CONTRACTOR ADDRESS UC# PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET Of BUIL INO.) P91C TEST(s)1 I HOW MANY <br /> Application t <br /> INSTALLATION WILL SERVE: RESIDENCE W COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF LIVING UNITS: ( NUMBER--O//F BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> CHA OF SOIL TO A DEPTH OF 3 FEET: -/-Al PIT/SUMP BOIL CHARACTER: WATER TABLE DEPTH <br /> EPTIC TAN GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS <br /> REATMENT%.ANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING UNE NO.d LENGTH OF LINER / DISTANCE TO NEAREST:WELL LI /� FOUNDATION--20 I PROPERTY LINE 7s <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED `❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEEPAGE PITS Yd'DEPTH 2�, SIZE �0NUMBER _DISTANCE TO NEAREST:WELL FOUNDATION / PROPERTY UNE 754 <br /> BUMPS /❑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 HEREBY CERT( HAT I HAVE PREPARED THIS APPLICATION AND THAHE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGU IONS O THE SAN JOAQUIN COUNTY.HOME OWNER OR L E ED AOENT'8 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOIeC FOR WHICH <br /> THIS PERMIT IS ISSUED 1 SHALL NOr£ Y ANY PERSON IN SUCH MAI ER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> SUB-COI(1TRACTING SI E CERTI IES T FOLLOWIN CERT THA IN THE PERF- ANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO � <br /> WOW AN'S COMPEN AT N F CALIF RNIA.' THE NT MUS CALL 24 HOURS IN ADVANCE FOR ALL REGLARED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> SIGNED � Clk�" ! ^, -���� <br /> TITLE:_ ��GG DATE:_ <br /> PLOT PIAN(DRAW TO SCALE)l9CALE 'to <br /> 1. NAMES OF STREETS OR ROAD EAREST 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 /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 1l' <br /> ' ,.�. pz hes +¢ . ... ........ '........... ... .. .... <br /> .......:...... ....................... ..:.................... <br /> :..... <br /> ........: ....:......;.....:......>..... <br /> .. <br /> :+.u¢C� <br /> ...�..... f .. .. .. <br /> ;. ;. .. <br /> .....` ....... :.... .... ........ �d5 <br /> ..... ..:.. . <br /> ;.. . <br /> t: 1 . <br /> .<......:.. . <br /> >� <br /> . <br /> fJ gD/t .. .. <br /> ........... <br /> ............... .. <br /> U .. .... <br /> .. _ <br /> ,_. <br /> / <br /> . ..:. .. .. ..... :. ................ .... .. � � 4 3k> ewi _ <br /> .......... `: . . <br /> ..... <br /> .......:. <br /> .... .... . <br /> :.....:......;........ .........1 ............... . <br /> .<.. .. .. :.. ..:................. ..... : .. . .'...... <br /> ....... . <br /> ;.. .. .................... .. <br /> . 4 r <br /> f <br /> A <br /> ............. <br /> ..1```141 ...:.. Nr.A} trt,•i,..:: <br /> . ;.. ... ..... .. <br /> ...../ y ..... :.. /fit .... --- : .............. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE: �� <br /> AREA: t� <br /> TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY DATE <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE FEE INTO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE SA/PERMIT NUMBIRR INVOICE# <br /> 42Ito 51t/7 61v /0j2s/f6 010o3ag g <br />