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APPLICA' tOR LIQUID WASTE PERMIT <br /> JAN JOAQUhPNTY PUBLIC HEALTH SERVIC.- \...000" <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,445 N.SAN JOAQUIN ST., STOCKTON,CA 95201 0388 <br /> (209)4683420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Ci mPMU N T,'wU.Ui <br /> Application is hereby Bede to the San Joaquin County for a permit to construct and/or install the work described. This application <br /> is meds in corylianc,with San Joaquin Canty Development Titte, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health <br /> Services, Enviratantal Health Division. <br /> Jab Address/or APNN Z/Q'gL �/'s'/i�r^� /EtOH <br /> City Lot Size 2 <br /> 4`- �9/+f <br /> Durer•s Nems Eur.- F is.f' Address_Z/`1826..x/.%7a..-iCd+c� Phare 8 -d�� <br /> Contractor Gear/A.?v4V/'-' Address fr- e +r 46o-e llc# Phone <br /> Sub Contractor Address Lich Phone <br /> TYPE OF SEPTIC WORE• NEW INSTALLATION I I REPAIMADDITIOM I1 DESTRUCTION I I PERC TESTW)I I it..err 2 <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) rry�F_p!/ :}N� <br /> (Soi/ sa%J:6.�.r fTw d, rho.- se"'6c sys�j�r ,der9 Lass!Use Appikatbsf A5 J/'T GMrlr <br /> Installation will ser Residene! Camerciel_ Other_ <br /> NurMr of living unlbn_ Rusher of bedrooaMt_ Nu,ber of scip os:_ al <br /> Character of soil to a depth of 3 fast: Pit/sUp Solt Character: Water Table Depth <br /> SEPTIC TANNIBREABE TRAP D TYPO/Mfg Capacity No. Cosparteenta_ <br /> PRO TAEATNEMT PLANT I ) Distance to nearest: Well Foundation Property line <br /> LIFT STATIOMD Site_ Type of PUIp SW Oil Separator (enclosed system) <br /> LEACHING LINE D No. A length of linea Distance to Nearest: Welt_ Foundation_Property Line <br /> FILTER BED [1 Width_ Length_Depth_ s s Well_ Foundation_Property Lira c <br /> MOUNDED D Width_Length_Depth_ a e Well_ Fondetion_Property Line 1 <br /> SEEPAGE PRS D Depth_ Size Hunter_ e ^ Well_ Foundation_Property Line T <br /> SUMPS D Width_ Length_Depth_ • • Well_ Foudation_Property Line <br /> DISPOSAL PUMPS D Width_Length_Depth_ ^ ^ Well_ Foundation_Property Line f <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances <br /> and State Laws, and guise and Regulatione of the San Joaquin Canty. Hose owner or licensed agenda signature certifies the followings <br /> °1 certify that in the perfornence of the work for Which this peratt is issued, 1 Awl net aploy any person in such a inner as <br /> to becoee subject to worknsNa copenaation laws of Californis.e Cortractorra hiring or subcontracting signature certifi ea the <br /> following: "1 certify that in the performance of the work for which this penit is issued, I shall a ploy persons subject to warkeen•s <br /> colpensation laws of California.^ <br /> TY apploset Mat aall 24 hour.Y draw far etl.wished Inrputism Covplete drawing Gt.. <br /> Signed X Z,/ / //9r <br /> 9 Title: awr/r Data: /0-/j/-95/ <br /> PLOT P (Draw to Scale) Scale_• to <br /> 1. Noses of streets or roads nearest to or bounding the property. 4. Location of house sauege disposal syet. or <br /> 2. Outline ofthe property, with diversions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dinersioned outtines and location of all existing and proposed 5. Location of Wella within real us of 150 ft. on <br /> structures, Including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> tl <br /> a Y' B• Y/ Z 9. <br /> PL BLI HEALTH ;ERV CES <br /> o N <br /> o ' L <br /> FOR DEPARTMENT USE ONLY o <br /> Application Accepted by /�["" `%!/C-./ Date: e-4r-/ rea: B70 <br /> Tank, Pit or Sup Inspection by Data / / Final Inspection by <br /> Additional Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE FEE INFO AMOUNT REMITTED CNEC CASH RECEIVED BY DATE( SRI PERMIT NUMBER INVOICE I <br /> to <br />