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- APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WE8ER AVENUE, STOCKTON, CA 95201-988 M <br /> Aci <br /> (209) 488-3420 (),f <br /> OP <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Trlplk$t11 <br /> APPLICATION IB HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS AMICATION IB MADE IN COMMIANCE WRIT BAN <br /> JOAQUIN COUNTY DEVELO EW� CH,A/pTpp����ND I�PTANDARDSOF BAN JOAQUIN COUNTY PUBLIC HEALTH BERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> 9 ✓/�//J �C/Jt ��, <br /> JOB ADORE66IORPJ# Cffl[ /Ci[,../C /G//Y LOT SIZE � <br /> OWNER'S NAM � / /CL�4���Lj �DDPEP <br /> CONTRACTOR; ADDRESS LIC# RHONE <br /> SUB CONTRACTOR ADDRESS LICI RHONE <br /> TYPE OF SEPTIC WORKNEW INSTALLATION ❑ RIPPNR/ADOTION ❑ DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMRTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET <br /> TOFF BUILDDIINNO..11 PFRC TFlibl l 1 NDW MANY <br /> IMSTALUTION WILL SERVE RESIDENCE ❑ COMMERCIAL ❑ OTHER a � <br /> NUMBER OF UVINO UNIT$: NUMBER OF SETMOOMS: NUMBER OF EMMOVIS81 S, q6. N <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PT/SUMP BOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANKJGREASE TRAP ❑TYMN.IFG CAPACRY NO.COMPARTMENTS <br /> PKO TREATMENT KANT ❑ DISTANCE TO NEARFIT: WELL__ FOUNDATION PIDK T UNE <br /> LIFT STATION❑ SRE TYPE OF PIMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING UNE ❑ NO.i LENGTH OF LINER DISTANCE TO NEAREST:WELLFOUNDATION pRCKSTY UNE <br /> FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION P OKR LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION P KR UNE <br /> SEEPAGE RTS ❑DEPTH BRE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREei:WELL FOUNDATION RgPERTY UNE <br /> DISPOSAL PONDS ❑MOTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS AMICATION AND THAT THE WOW WILL BE DONE IN ACCOSOANCE WRIT SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES <br /> ANOREODUTIONB OF EPAH JOAOUIN COUNTY.HOMEOWNEROR LICENSED AGENT'S SIGNATURE CERi1F1E8 THE FOLLOWING:'ICERTIFYiNAT IN THE PEPFOTOAANCE OF TME WOTK(OR WIIICII <br /> THIS RRMIT IB IB6UE .1 HALL EMKOY AVIV PERSON IN SUCH A MANNER AS i0 BECOME BUBJECi TO WOIKMAN'B COMR•ENBATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR <br /> SUB-COW RACTINO ON VRE E IFIES TME FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF TME WOR(FOR WHICH THIS PRMR IB ISSUED,I SHALL EMMOY PERSONS SUBJECT TO <br /> WO p(MAN'B COMP 6A ON OF CALIFORNIA." THE APKJCANi MUST CALL Z41m UL$IM ADVANCE FOR ALL REOURED IIM$pP�FC1�10/�M6. COMMETE DRAWING BELOW`. <br /> xSIONED% <br /> MOT MN(DRAW TO MALE)SCALE •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PRIDPT Y. 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 PROPEWY OR ADJOINING PROPERTY, <br /> 1400 <br /> _ i'U4LII II /.. <br /> FOR DEPARTMENT WE ONLY <br /> APPLICATION ACCEPTED By (DATE AREA: <br /> TANK,PT OR SUMP INSPECTION BY DATE / / FI L_PPECTI _ BY DATE ! / <br /> ADDITIONAL COMMENTS: <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODE FEEINFO I ANOUNTREMITTED CHF KASII RECEIVEDBY DATE SR/PETWIIT NURIM IBV0IOE0 <br /> l6 c JSP aso 0 S 7 0331 (O <br />