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APPLICATION FOR LIOUID WASTE PERMIT <br /> SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 <br /> (209) 460 3420 <br /> NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESsroP APNR <br /> S� {� LOT SIZE_ <br /> OWNER'S NAME P1Qrl%I'N�. ADDRESS y �i/Y-t.A <br /> PHONE <br /> CONTRACTOR zz ,LFp�LQ ADDRESS_ �1 L[/FYn.// ._,) /"Q UCI R10NE <br /> SUB CONTRACTOR A, /�/(iL tr/ ADDRESS <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IQ REPAIRIADDITION ❑ Du"MTION ❑ <br /> (NO SEPTIC SYSTEM PERMITTED IF RIBUC SEWER IS AVAILABLE WITHIN ZOO FEET OF BUILDING.1 PERC TESTI.)I 1 NOW MANY <br /> APwLn484A . <br /> INSTALLATION WILL SERVE: RESIDENCE 1IYCOMMERCIAL 11OTHER ❑ <br /> NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOM$:_'f_ NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF J FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> U1FO ,( <br /> SEPTIC TANK/GH6E TRAP ❑Typiu �/ CAPACITY <br /> NO.COMPARTMENTS d� lX• <br /> PKG TREATMENT PUNT ❑ DISTANCE TO NEAREST: WEFOUNDATION ^l/cr %1OPERTYUNE �S�Z— Q�l <br /> LIFT STATION❑ SIZE TYPE OFLEACHLEACHINGPUMP //yy BAND OIL SEPARATOR(ENCLOSED SYSTEM) ���� <br /> LEACHING LIME NO.A LENGTH OF LINER J/J /�T DISTANCE TO NEAREST:WELL�.POUNDATION 11 PgpPERTY UNE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE V. <br /> SEEPAGE RTS ❑DEPTH SIZE_NUMBER DISTANCE TO NEAREST:WELL�']'•� FOUNDATION PROPERTY LINE �• <br /> SUMPS WIDTH fTLENGTN S�fOEPTH�r DISTANCE TO NEAREST:WELL(' �PoUNDATN)N��KnTy LINE Zg / <br /> DISPOSAL PONDS WIDTH LENGTH DFPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT INTHE PERFORMANCE OF THE WOR(FOR WHICH <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 /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIF RNIA.' THE APPUCAN UST CALL 34 HOURS IN ADVANCE FOR ALL REOURED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> SIGNED X I/L/lN`i.. b� TITLE: I �DATE: /0%F /J <br /> PLOT PLAN IORAW TO SCALE)SCALE 'to <br /> I. 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,MTN DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3,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 AS PATIOS,DRIVEWAYS,AND WMKS. THE PROKRTY OR ADJOINING MOPERTY. <br /> It �V, <br /> 0 <br /> I <br /> +IJ � <br /> /!ovx' ��BLIG-FdEPI TH ,F_R it d <br /> Yv <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY O Ji (,( L DATE: /1J ^, AREA: q <br /> TANK,RT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY�� DATE If <br /> ADDITIONAL COMMENTS: � !T ovvk M, S 1 <br /> AeA <br /> v' f1AAA # <br /> ACCOUNTING ONLY: AID' FAC# <br /> DECODE FEE INFO AMOUNT REMITTED CHECK'/CASH RECEIVED 11Y DATE SR/PE3IMIT NUMBER INVOICE <br /> Z ° 10' 6 1 2 3 <br /> -7 ( <br />