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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX%8, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 4003420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Tripfinttl <br /> APPLICATION 19 HEREBY MADE TO THE SAW JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110.3 ANO THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDPES&OR APNR'is4 t �/� £ It� CITY ✓J„/..F-. LOT SIZE <br /> ►.o OWNER'S NAME i UT ADDRESS �QyaQ� PHONE <br /> CONTRACTOR /> /� ADDRESS /L) (ICJ RIONEy-QZ7 <br /> SUB CONTRACTOR ADDRESS LIC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ®. DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 300 FEET OF BUILDING.) PIERC TESTW I I HOW MANY <br /> ADNloutlon I <br /> �IN&TAILATON WILL tFAVE: RESIDENCE®- COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF LIVING UNITS:J NUMBER OF BEDROOMS: NUMBER OF ERPLOYEE&: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER- WATER TABLE DEPTH 1 <br /> —SEPTIC TANWMR C TRAP ❑TYrE:MFG CAPACITY NO.COMPARTMENTS <br /> MO TREATMENT PLANT❑ DISTANCE TO NEAREST: WILL FOUNDATION PIOPERTY UNE <br /> UFT STATION❑ASSIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) 1 <br /> —LEACHING UNE E3 M.&LENGTH OF LINES !-Un I DISTANCE TO NEAREST:WELL ,rte FOUNDATIONS nn PFIOPERTY(HIE <br /> RLTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 7 <br /> MOUNDED I❑-B WIDTH LENGTH DEPTH DIGI'ANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> RtI <br /> SEEPAGE <br /> TS DEPTH SIZE Z NUMBER J_DISTANCE TO NEAREST:WELL-4szL—FOUNDATION i(Ih PROPERTY UNE ll.0 <br /> SVM% ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL POND& ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> SAND REGULATIONS Of THE BAN JOAQUW COUNTY.HOME OWNER OR UCENSED AOENT'8 SIGNATURE CERTIFIES THE FOLLOWING:'I CEPTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME BUBJECT TO WOEKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIE8 THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOE(FOR WHICH THIS PERAUT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAW�S/OFF�JCALIFORNNIIA.'' THE APPLICANT MUST CALL N HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. IN <br /> COMPLETE DRAWING BELOW. <br /> SIGNED X ///� 4ZO111 - TITLE: ,:2� DATE: <br /> PLOT RAN mRAW TO SCALE)SCALE 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRDPoSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPOBAL BY67EM6. <br /> J. 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 PROPERTY OR ADJOINING PROPERTY. <br /> �� <br /> �} S 'bIo <br /> Lx <br /> : : <br />