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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.D.BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 962010388 <br /> (209)4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tripliutol <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOW DESCRISED.THIS APPIJCATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRO <br /> NMENTAL HEALTH DIVISION. <br /> I /�� S� <br /> JOB ADDRESS/SDR APNR may/ CITY /� LOT SIZE <br /> OWNER'S NAME ICJ/U C5 J�/�(/7FFl(/ DRESS <br /> CONTRACTOR /'// ADDRESS /,/ UCS PHONE / <br /> SUBCONTRACTOR_/f/L/I C -G-L _AODRESS �• 2/�� /''�/�7/Ln LACI PHONE�� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADOITTTI��~ON —TRUCTION❑ <br /> [NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PER.TESTI.11 I HOW MANY <br /> INSTALLATION WILL SERVE: RESIDENCE% COMMERCIAL❑ OTHER❑ <br /> NUMBER OF UVING UNITS:_NUMBER OF BEDROOMS: NUMBER OF BAPLOYEES: <br /> CHARACTER OF SOIL TOA DEPTH OF 3 FEET: �I%/> PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANIGGREASE TRAP [ITYPE/MFG CAPACITY NO.COMPARTMENTS <br /> _ MG TREATMENT PUNT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> LIFT STATION❑���SIIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM( <br /> LEACHING Uge NE NO.6 LENGTH OF UNES�l/ �r DISTANCE TO NEAREST:WELL�TFOUNDATION /PERTY LINE Sb <br /> FILTER BED (❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE C <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE !\ <br /> DISPOSAL PONDS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> 1 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 /> AND REGULATK)NS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT 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 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED II.N.SSPPEECTIONS. COMPLETE DRAWING BELOW. <br /> tel <br /> SIGNEDX �A TH LE <1-/ 'yiZ/f/'J-[i<<-�. GATE: �'LO/ <br /> PLOT PIAN(DRAW TO SCALE)SCALE -IP <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4.LOCATION OF MOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTK)N. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. 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 WAL". THE PROPERTY OR ADJOINING PROPERTY. <br /> i=-e 74 G <br /> fl l K <br /> 41, ji <br /> 1 <br /> cry <br /> -5 vU ��' ''pper��A►�_o <br /> ( 1 <br /> all It <br /> 112, <br /> Mir'11�ir <br /> JUN 2 0 1996 <br /> ra <br /> SAN JCJAQO_ --„r Ce, (� <br />