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"IPPLICATION FOR LIQUID WASTE PERMIT <br /> Sw..'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RO, SOX 388, 304 EAST WEBER AVENUE,STOCKTON, CA 95201-388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM PATE ISSUED <br /> ICompht&in Tripiicati} <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITWSAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.111000..3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEER�VECEB,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APNJ►—l� { �; I/ /,erCTTYf... I r—Qm tir+(7 LOT SIZE <br /> / <br /> OWNER'S NAME ctr I ( 1C 1�( l�`ADDRE89 -i N�6 PHONE <br /> CONTRACTOR S C ADDRESS uCN PHONE <br /> SUB CONTRACTOR ADDRESS LIC# PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION © REPAIR/ADDITION ❑ DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Pu RC TESTial[OH-AN MANY C <br /> APPllostlon <br /> INSTALLATION WILL SERVE: RESIDENCE 13COMMERCIAL ❑ OTHER 13 <br /> r— <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: - <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TAHIUGREASE TRAP CJ TYPE/MFG CAPACITY NO.COMPARTMENTS <br /> PKO TREATMENT PLANT❑ DIBTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE ^Z <br /> Ljglr 4TATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR)ENCLOSED SYBTEMI <br /> LEACHING UNE 0 1 NO.b LENGTH OF LINES DISTANCE TO NEARE87:WELL FOUNDATION PROPERTY LINE l <br /> FILTER BED C3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 <br /> MOUNDED ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL - FOUNDATION PROPERTY LINE R` <br /> SEEPAGE PIT& ❑DEPTH SIZE - NUMBER. DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br />` SUMP& ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE <br />! DISPOSAL POND& ElWIDTH LENGTH DEPTH DISTANCE TO NEAREST.WELL FOUNDATION PROPERTY LINE <br /> 1E I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOA43VIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ' <br /> AND REGULATIONS OFTHE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CMIFYTHAT I LATHE PERFORMANCE OFTHEWDRK FORWHICH <br /> THIS PERMIT is ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWCMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> f SUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 @HALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HGUR&IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> SIGNED X (LA <br /> TITLE: 1c ' <br /> BATE: <br /> PLOT PLANW 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 PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH 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 WALK8. THE PROPERTY OR ADJOINING PROPERTY. <br /> Ae <br /> .... <br /> :.. . <br /> _ . <br /> SEPI . 51995- ;SM <br /> .. <br /> ... <br /> 0I 41 c.0 <br /> �-� 0VICAL <br /> 1iEA TN f)f.VOIR Sl <br /> fv .. <br /> p =/Jt - FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 'TQ DATE: �� AREA: <br /> TANK.PIT OR SUMP INSPECTION BY—,- DATE I ! FINAL INSPECTION BYDATE-7� -� <br /> ADDITIONAL COMMENTS: - <br /> ACCOUNTING ONLY: AID# FAC# � \ <br /> Pf CODE FEE INFO AMOUNT REMITTED CHEC JCASH RECEIVED BY DATE &R 1 PERMIT NUMBER INVOICES G <br /> oo18'/ Lzcn� 9 �S S C1a 3 0 SSS <br />