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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,445 N.SAN JOAQUIN ST., STOCKTON,CA 95201-0388 <br /> (209)4683420 <br /> MON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iCampiats In Triplicate) <br /> Appticarion is hereby made to the San Joaquin County for a permit to construct and/or install the wort described. Title application <br /> is 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 APN#- `I70 /V. G////Rrt/ AUae CitY�! O '— Lot S'.ze <br /> ,-R1C j <br /> Owner's Name C/!K/Sr`li Address 4/c/ ,/ /V L111-1, -4i� 0-IC; _Phone�,E,a? 7/9g <br /> Contractor_ t= 2 Address Lfc# Phone <br /> / Sub Contractor Address Lick_ Phone <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION[] DESTRUCTIOM,E'Z PERC TEP,TbI 1 1 Now m..I <br /> (NO SEPTIC SYSTEM PERMITTED 1F PUBLIC SEVER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> J Lan/Use Appfaation J <br /> Installation will serve: Residence_ Conrrrcial_ Other_ <br /> Number of living unites Number of bedrooms_ Nuober of amployaut <br /> Character of soft to a depth of 3 faetm Pit/Sump Solt Character; _Mater Table Depth <br /> SEPTIC TANKISHEASE TRAP 0 Ty{,* ac <br /> /Mfg Capity= No. Compartments <br /> PKO TREATMENT PLANT C I Distance to nearest: Well Foundation Property Line <br /> LIFT STATiON[1 Size_ Type of Pump Send Ott Separator (enclosed system) <br /> –" LEACHING LINE 11 No. A length of 1!nes Distance to Nearest: WettFoundation Property Limit <br /> FILTER BED 11 Width Length__Depth " " well Foundation Property Line <br /> MOUNDED ❑ Width Length______ Depth " Wall Foundation Property Line <br /> SEEPAGE PITS [1 Depth size Number " " Jell Foundation Property Line <br /> SUMPS [I Width Length___Depth " " Well Foundation Property Line <br /> DISPOSAL PONOS [) Width Length Depth " Well F ouridation Property line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances <br /> and State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent/s signature certifies the following <br /> "1 certify that in the performance of the work for baAch this permit is issued, 1 shall not employ any person in such a manner as <br /> to become subject to workman's compensation laws of ca!ifornie." Contractor's hiring or cub-contracting signature certifies the <br /> t 7vC foitowing: "I certify that in the performance of the work bor which t!tis permit is issued, I shall employ persons subject to workman's <br /> compensation Laws of California.-- <br /> The <br /> alifornia."The epPG••st man <br /> nail 14 beans In dwmea far aR rquArai(napeatimm. Caplets drawing below. <br /> Signed 'i�h,, - �i� _ Title: O!_cJNFDate:_Q 8/ <br /> i <br /> PLOT PLAN (Draw 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 <br /> 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage disposal 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. <br /> 13A osi­ <br /> 44T -4A lsf6 <br /> Y <br /> LTCC 4 A4 <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> Application Accreted by S�LJIN�"�m,.r�1 Date: <br /> Tank, Pit or Sup inspection by Date / / Final Inspection b- Deteltlz 9u <br /> Additional Comments: <br /> ACCOUNTING ONLY: AID# FAc# <br /> FE CODE FEE INFO AMOUNT REMITTED CHECA ASN RECEIVED BY DATE .,_INVOICE/ <br /> -,a <br /> oa39o3 <br />