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APPLICATION FOR LIQUID WASTE PERMIT <br /> I : AN-JOAQUIN COUNTY PUBLIC HEALTH SERVIG.- i <br /> ENVIRONMENTAL HEALTH DIVISION ' <br /> P,O. BOX SW 304 EAST WEBER AVENUE STOCKTON. CA 95 I-M <br /> (209) 408.3420 , <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> `^ {CemplBlr in Tripiketal <br /> APPLICATION IS 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 THE STAN AiKZB OF SAN JOAQUIN COUNTY PUSUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR AI'Na< U ' ♦ CIT}/ _–1/►�_e 1A.,, LOT SIZE <br /> S <br /> OWNER' NAME 00LU ADDRESS i r j{T; 1ItC.-.�'1..- " PHONE Q <br /> V <br /> CONTRACTOR _vv L S� . S11'A� _ADDRESS . (.0 i _%ov- UJ CJL L1car Z 513 PHONE ��� <br /> SIRS CONTRACTOR ADDRESS UCI pHONT <br /> • TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPA"VADDITION Ir DESTRUCTION <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING) PERC TFATIO 1 1 HOW MANY <br /> Appnoation Ir <br /> INSTALLATION WILL SUM: RESIDENCE Ip, COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF LIVING UMTS: NUMBER OF SEDRONUMBER OF EMPLOYEES: <br /> IL { <br /> CHARACTER OF SOTO A DEPTH OF 3 FEET; 4 MS: PITISUMP SOIL CHARACTER,.- OL` WATER TABLE DEPTH a <br /> SEPTIC TANK/4REASE TRAP ❑TYMWFG —� _..— C <br /> CAPACITY NO.COMPARTMENTS <br /> PKG TREATMENT PLANT© DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE C <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) <br /> LEACHING LINE � NO.&LENGTH OF LINES_ WE <br /> X � . ._DISTANCE TO NEAREST: LL FOUNOATWNPROPERTY LINE <br /> -' FILTER BED 17 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED D WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL. FOUNDATION PROPERTY LINE [ <br /> r� SEEPAGE PITS DEPTH �SIZE (Q 11 NUMSER_;;�L DISTANCE TO NEAREST;WELL _jjW FOUNDATK)N_,5Q PROPERTY LIHE__5_ � <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE t, <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAQUINCOUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> SU"ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> .r--, WORKMAN'S COM SON LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24"OUR&IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> SIGNED% .. TITLE; 1 T <br /> —- r ' DATE: ti'i <br /> 1 <br /> PLOT PLAN 1DRAW t0 SCALE)SCALE •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE 03SPOSAL 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 /> r^. _ ]� 't <br /> �7 <br /> V <br /> .. . .. �..._ 1 .. <br /> ... <br /> ..... .s...._ I.....: <br /> ... ... 4 <br /> K <br /> y • : _ <br /> �— <br /> ©yot ... <br /> �. <br /> y <br />