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APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RO, BOX 388, 304 EAST WEBER AVENUE, STOCKT'ON, CA 952011 X88 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROCK DATE ISSUED <br /> IComphh in Trwlkmtol <br /> APPLICATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AN01OR INSTALL THE WORK DESCRIBED, THIS APPLICATION IS MADE IN COMPLIANCE WITk SAN <br /> JDAOUIN COUNTY DEVELOPMENT`TITLE,CHAPTER <br /> j9-11 10.3 AND THE STANDAR/DS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR�APPNNyp r 1V- / CITY /�- I LOT SIZE <br /> OWNER'S NAME / 'V�+' .e f <br /> /1•�. rF*V� bRE65 � 102 <br /> bd I W• PHONJ'i,? <br /> . CONTRACTOR 17 ADDRESS UCN PHONE Y <br /> i <br /> SUBCONTRACTOR ADDRESS LICA PHONE <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAJRIADDITION ❑ DESTRUCTION ❑ <br /> {IVO SEPTIC SYSTEM PERMITTED 1F PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF 136ILVIN0.1 PERC TFATIO 1 1 HOW MANY <br /> PPIIonBon# <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL 13 OTHER A G/ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF HW1 YE"I fJ �/�/�/ ,�FI..� � 1 <br /> f CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH ,�'� !if <br /> P OREAS 1 ZYP£1MFG __-7^�y / CAPACITY NO.COMPARTMENTII <br /> PKG TREA NT PLANT DISTANCE TO NEAREST: WELL ✓Dom" FOUNOATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) <br /> LEACHING UNE © 40. OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIDTH LENGTH DISTANCE TO NEAREST:WELL FOVNOATIO RTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH D EARFS FOUNDATION PROPERTY LINE <br /> SEEPAGE%T8 [3 DEPTH SIZE NUMBE ANCE TO NEAREST:WE OUNDATION PROPERTY LINE <br /> .'SUMPS ❑WIDTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE r <br /> DISPOSAL POND$ © LENGTH DEPTH OtSTANCETO NEAREST:WELL FOUNDATION PROPERTY LIN <br /> I HEREBY CERTIFY THAT I 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 REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFYTHAT 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 /> 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 <br /> WORKMAkF+S'C�E qRS TION LAWS OFC FORNfA.' THE APPLICANT MUST,CALL 24 MUMS IN ADVANCE FOR ALL REQWREO INSPECTIONS, COMPLETE DRAWING BELOW. 5 <br /> / Ut. 0 <br /> SIGNED X TITLE: f7 ' � �.-SC7 PATE: � ,I <br /> PLOT PLAN IDRAW TO SCALE)SCALE "to Vit <br /> 1 NAFAC nc.97-9P -Q nR RO RFST TO OR RnONFANO- gpFRTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM Op PROPOSED <br /> S <br /> --- .—_T --��PH Ili. <br /> ON i <br /> 4 <br /> 77EE <br /> `I <br /> f <br /> C1 <br /> r <br /> JF <br /> I ► <br /> J1' I I: <br /> Jit <br /> t ILII <br /> PLATE 16 <br />