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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ..r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)468.3420 <br /> _ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Try6cstf) <br /> APPLICATION 10 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. THIS APPLICATION IS MADE IN CO <br /> JOAOUIN COUNTY DEVELOPMENT TITLE, <br /> ,CHAPTER <br /> '9-11110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH RVI <br /> JOB ADDRESS/OR AR), V �B`' 'L/• /! / -Z �,/ ^/ CITY <br /> ��f�f// <br /> M� OWNER'S NAME • '/ SS /�O {/V • O'er /�jJ `"'D(. PHONEY <br /> CONTRACTOR ADDRESS LMf PHONE <br /> SUB CONTRACTOR ADDRESS LICI ROM <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPANUADDITION ❑ DESTRUCTION❑ �— <br /> SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) 4W /1;— <br /> INDW I I HOW MANYf <br /> INSTAlUT10N WILL SONE; RESIDENCE❑ COMMERCIAL❑ OTHER� � /7NUMBER OF UVINO UMTS: NUMBER OF RWROOMS: MUMMER OF EMPLOYEES: ✓ Gf� <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITMUMP SOK.CHARACTER: WATER TABLE DEPTH <br /> GREAS I�jYTE/MFO ? CAPACITY 14 NO.COMPARTMENTS <br /> PKO TREA IT PLANT DISTANCE TO NEAREST: WELL 3a-o FOUNDATION PROPERTY LINE <br /> _ UFT STATION❑ SITE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEMS <br /> LEACHING LINE ❑ NO. OF LINED DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY U <br /> FILTER RED ❑WIDTH LENGTH DISTANCE TO NEAREST:WELL PoVNDATO RTY U <br /> MOUNDED ❑MOTH LENGTH DEPTH DI CARE FOUNDATION PROPERTY U <br /> SEEPAGE PITS ❑DEPTH SIZE NUMBER <br /> ANC <br /> TO NEAREST:WE FOUNDATION POPERrY U <br /> SUMPS ❑WIDTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY U <br /> DISPOSAL FONDS ❑ LENGTH DEPTH DISTANCE TO NEAREST:WELL FOVNDAT.. PROPERTY U <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STAT <br /> AND REGULATIONO OF THE SAN 30AOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OFT <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.' CONTI <br /> SUB-CONTMCTINO SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY R <br /> NgR(MA TON LAWS OF FORMA.' TETE APPLICANT Ml1ST CALL 24 HOURS IN ADVANCE FOR ALL REOUR®/NfPECNONS. COMPLETE DRAVVeMO BELS <br /> SIGNED X TITLE: S/ �-f 7 (, DATE: N <br /> PLOT PLAN MRAW TO SCALE)SCALE 'Is <br /> I c e+ocrrS nw m TO ON I nUNMNq RTY. S.LOCATION OF HOUSE SEWAGE DISPOSAL SYFM <br /> _ <br /> 1 <br /> I Ii A<iL1 <br /> i <br /> w A'S <br /> P 1T I- <br /> - I I s— <br /> it , PAI <br /> L ,'J I' MAY <br /> &AN,UAO <br /> cNVI.RV 4 <br /> R" I <br /> FOR DEPARTMENT USE ONL '- /J9 <br /> APPIWATION ACCEPTED BY DATE: S-,� f ,� AREA; <br /> � E <br /> TANK,RT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY <br /> �h <br /> ADDITIONAL COMMNT <br /> ES: ���IWJ - <br /> ACCOUNHNO ONLY: .. // AID, FAC• <br /> PE CODE FEE INTO AMOUNT REMITTED NEC ASH RECEIVED fY DATE SR/PERMIT NUMBER INVOICE <br /> P05? <br />