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APPLICATION FOR LIOUID WASTE PERMIT <br /> PUBLIC <br /> ._._.-JOAQUIN COUNTY PUBLIC HEALTH SERVICE_.,, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0389 <br /> (209) 468-3420 2 0 3L3� <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ✓ J J <br /> (Complete in Triplicate) <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> 3-2fh r <br /> JOB ADDRESS/OR APNI 9 <br /> ' � LOT SIZE Lc <br /> � <br /> OWNERS NAME /IOMI-11 ADDRESS -PHOME &'f7-3630 <br /> CONTRACTOR ADDRESS LNI PONE 3,K / <br /> v <br /> SUB CONTMCTOR ADDRESS UCS PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRADOITION ❑ DFRTRUCTON ❑ <br /> INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 20D FEET OF BUILDING.) PERU TESTRI 1 I HOW MANY �3 <br /> SJ1d�Ydy S foj i S5/J jAs^J fJVr�9 ) APw %'laetlon// J <br /> I95l GY <br /> INSTALLATION WILL SERVE: RESIDENCE d COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF WINO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYER: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITMUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANKUOREASE TRAP ❑TYPEUMFO CAPACITY NO.COMPARTMENTS <br /> PKG TREATMENT PANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR NCLOSED SYSTEM) <br /> LEACHING UNE 13 NO.&LENGTH OF LINES d E NEAREST:WETL FOUNDATION PROPERTY UNE <br /> FILTER BED 11 WIDTH LENGTH DEPTH dtn <br /> E TO EAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTH DEPTH d ETO ANEST:WELLFOUNDATION PROPERTY LINE <br /> SEEPAGE PTS ❑DEPFM SIZE NUMBER//���\ E TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> am" ❑WIDTH LENGTH DEPTH ST ETO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DI ANCE TO NEAREST:WEU FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVbRKAI L BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FORNOIICH <br /> THIS PERMIT IS ISSUED,1 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 /> SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 EDDY IN ADVANCE FOR ALL REQUACD INSPECTIONS. COMPLETE DRAWING BELOW. <br /> 61GNE0% TITLE: r�DATE: <br /> OT MN IDRAW TO SCALEI SCALE.w 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. 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, a. 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 /> % f'o2210) <br /> TEST X10!T <br /> T <br /> c r <br /> ♦ • ° <br /> .K <br /> /tb <br />