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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, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION IS HEREBY Mi4IE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11,1,/0.3 fA•ND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNI ' //�/�//I% 9l Poend /G , �S� / CITY r/..1 (-lm PLOT SIZE /`otO�•a <br /> OWNER'S NAME 9(�P. 1" /V61-1hG /I ^C(�O I ADDRESS )" L"l�� �i / L;J���7 ce/h <br /> A� )7 PHONE <br /> CONTRACTOR _ AbbRESS \ _ A , eJ-./i17,7 y�GQ Sf/�/I d ������NE �/7p?' <br /> SUB CONTRACTOR ADDRESS LICI PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ <br /> (NO SEPTIC SYSTEM KRMITTFD IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTA)I 1 HOW MANY <br /> AvvSoetlon l <br /> INSTALLATION WILL SERVE RESIDENCE COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF LIVING UNITS:_ NUMBER OFqF BE�^IIMOOM � NUMBER OF EMPLOYEES: /7�/ <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: �9 1T/SUM/P SOL CHARACTER: ^^ WATER TABLE DEPTH CPv/ <br /> SE`T1C TANK/GREASE TRAP OTYPEIMFG f /^ / /� CAPACITY I QLD Q I NO,COMPARTMENTS <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND <br /> SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING LINE 0 NO.&LENGTH OF LINES ' )` ✓ DISTANCE TO NEAREST:WELL 0 C ' FOUNDATION-ten PROPERTY UNE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> -' MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE RTS ❑UEPTII SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE T <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE J <br /> I HEREBY CERTIFY THAT IH 9VE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE 1 AN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'i CEKTIFYTHAT IN THE PERFORMANCE OF THE WORK 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO Ob <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> SIGNED X �`�'�L,//yL i TITLE: L/ GJn DATE: ��- _w rnrnCL- <br /> \v <br /> PLOT PLAN(DRAW TO SCALE)SCALE 'to <br /> 1. NAMES OF STREET S OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 0 <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 `Y <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> b es <br /> 3 <br /> ,20o1 <br /> 0 <br /> , Y' i3. <br /> �� X / 1 SPT -l�+G�rYf..l.ttJ 1 LFII.{y I Y <br />