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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEP,VICE1 � <br /> ENVIRONMENTAL HEALTH DIVISION U ff O L <br /> P.O.BOX 388, 445 N.SAN JOAQUIN ST., STOCKTON,CA 620}tB� �-�=-- <br /> (209)4683420 I1 f //jj(( <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE •�� <br /> (Complete is Triplicate) <br /> Application is hereby made to the San Joaquin County for a permit to construct end/or install the work descrt <br /> is made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin Court <br /> Services, Environmental Health Division- <br /> Job Address/or APN# ��� �V _J'� - l` �I C���� f ,(City �C>C�� Lot Size_ <br /> Owner's Name {Address -6C-- a 1\( L,i_ w Vt� � Ph, <br /> Contractor—(L,) t�� F��>Z Address Lic# P <br /> _ Sub Contractor Address Lic# PI- <br /> TYPE <br /> FTYPE OF SEPTIC WORK: NEW INSTALLATION P4--- REPAIFUADDITION I I DESTRUCTION I I PERC TEST(a)III Hew an <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> lei Use Application t <br /> Installation will serve: Residence_ Comnerciat '� Other_ <br /> Nurrber of living units:_ Nuaber of bedrooms: Number of enployeae:_, o <br /> Character of soil to a depth of 3 feet: `\Cl rcJtr!ylt/Sunp Solt Character: �-47(, �d? Water Table Depth_ <br /> SEPTIC TANKIGREASE TRAP,,((�� ❑ Type/Mfg J= A c' h Capacity -�©O d cc)A/No. Cospa <br /> PKG TREATMENT PLANT 01A Distance to nearest: Wet Foundation-- - Property <br /> LIFT STATION❑ Size_ Type of Pump Sand oil Separator (enclosed system) <br /> LEACHING LINE ❑ No. 8 length of lines 3 -- 100 1 Distance to Nearest: Well 0 O Foundatior6200 Propert <br /> FILTER BED ❑ Width Length Depth Well Foundation Propert <br /> MOUNDED (I Width Length Depth Well foundation Propert <br /> SEEPAGE PITS LI Depth Size Number Well Foundation Propert <br /> SUMPS ❑ Width Length Depth " " Well Foundation Propert <br /> DISPOSAL PONOS ❑ Width Length Depth Well Foundation Propert <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin Co <br /> and State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifie <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in s, <br /> to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> _ following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subje <br /> cortpensat' f California-" <br /> The applicast must a hours is a vancr r aN required laspections. Complete drawing below. <br /> Signed X Title: Date <br /> PLOT PLAN (Draw to Scale) Scale /I " to `L/o /-- <br /> 1. <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage dispo[ <br /> 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage di <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius <br /> structures, including covered areas such as patios, driveways, the property or adjoining prope <br /> and walks. <br /> am m4r <br /> Zip- <br /> �1 a <br /> n <br /> PAY! <br /> - s — RnC( <br /> c <br /> AU <br /> J • IN:)C �U <br /> TAL <br /> n <br /> S CGt�e c� 7���r S �n'�`��l at• FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date: h, Area:, <br /> Tank, Pit or Sump Inspection by )ate / / Final Inspection by <br /> a <br /> Additional Garments: !'O c,' / L i` 3 <br /> ACCOUMTINO ONLY: AIDM FAC# <br /> G ! l <br /> PE CODE FEE/INFO AMOUNT REMITTED HEC CASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE <br />