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APPLICATION FOR LIOUID WASTE PERMIT <br /> SAN JOA(IUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,445 N.SAN JOAQUIN ST., STOCXTON,CA 95201.0388 <br /> (209)4683420 <br /> RON REFUNDABLF PERMIT EXPIRES 1 YEAR FROM DTI!ISSUED <br /> IComptoto b Trlpiksts) <br /> Application is hereby made to the San Joaquin County for to <br /> to construct and/or install the work described. This application <br /> 16 made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or City Lot Size <br /> s Name � -�- <br /> Owner' z cess Phone <br /> Contractore(G����-+� �iJl Address 76-7 t� s �/•flyLi cm ✓oZ�7-Z�a Phme�6�c1/AS <br /> \� Sub contractor Address Lich Phone <br /> TYPE OF SEPTIC WORX: NEW INSTALLATION(I EPAIRIA ITIoi,q DESTRUCTION I I PERC TEST(a)I I How oaF <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AYAI WITHIN 200 FEET OF BUILDING.) <br /> Lamin Use Aitplisaden I <br /> Installation will serve; RasidenceY Commerciel_ Other_ <br /> ^� weber of ilving unites / Number of badr000�mmsl� Muamber of employees: / <br /> character of soil to a depth cf 3 feet:__ Pit/Sump 6oil Character: _ Water Table Depth (t0 <br /> SEPTIC TANXIOREASE TRAP 17 TyFV/Nfg U Capaci ty T No. Compartments <br /> PXG TREATMENT PLANT [ 1 Distant to nearest: Welt Four6ation Property Line <br /> LIFT STAT!DNI1 Size,____ Type of Pump Send Oil Separator (enclosed system) <br /> LEACHING LINE [1 No. 8 length of lines Distance to Nearest: Veil Foundation Property Line <br /> r^ FILTER BED 0 Width Length__ Depth " " Well_ Foundation Property Line <br /> �) MOUNDED (L1 Width Length_ Depth " " Wel', Foundation Property Line <br /> I` \ SEEPAGE PITS k Depth 7 Size' Number i " Well I cc/ Foundation/C/t Property Line <br /> SUMPS ❑ Width Length Dopth " Well Foundation Property Line <br /> i <br /> DISPOSAL PONDS I Width Length Depth " " Well Foundation Property Line <br /> 1 hereby certify that I have prepared this app(icaticn and that the work wiul be done in accordene with San Joaquin County Ordinances <br /> and State Laws, and Rules and Regulations of the San Joaquin County. How, owner or licensed agent's signature certifies the following <br /> "I certify that in the performance of the work for which this permit is Issued, 1 shall not employ any person in such a marvner as <br /> ( to become subject to workman's compensation lows of California." contractor's hiring or sub-contracting signature certifies the <br /> following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's <br /> compensation laws of California." <br /> The applicant mumt as 24 bars in edvam�M'for <br /> `all r6gmkod impaCWM. ConpLete drawing below. <br /> �J Signed X IL,Z", �C.`', �J N-��1'r-�y.r Title.*--- t.� _Date., <br /> PLOT PLAN (Draw to Scale) Scale " to T <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, with dimensions and North direction, proposed expansion of sewage dieposal systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, Including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. LU� <br /> -AI <br /> L � � <br /> I ry T <br /> I <br /> FOR DEPAR MENT USE ONLY <br /> Application Accepted by Date. 1!Ares; Z ff(� <br /> Tank, or Sump Inspection by Dat inet Inspection by <br /> Pi e <br /> Additional comments: - <br /> A00011N7IN9 OmLY: AIDI rr�� FAC►' <br /> Pt CODE FEE INFO TMOUT REMITTED WECRtICASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE I <br /> 2 <br /> 1 7S_, <br /> DD �� <br />