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_ APPLICATION FOR LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> 304 EAST WEBER AVENUE, STOCKTON. CA 95202 S7 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPUANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TTIIT�L`EE,/CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUSUC HEALTH SERVICES,,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNO Ltz S' •T C!J5 �C(i � Z°'l C 7_ CITY � '' 1 d Z _ (' LOT S12E <br /> ' OWNER'S NAME .'-.//-�(t-1/ 'F- \l��' /-.J LY rIlESS_ —PHONE <br /> CONTRACTOR I�A I 1/lY .I ADDRESS UCI PHONE <br /> SUBCONTRACTOR ADDRESS UCR PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO NA REPAIR/ADDITION ❑ DESTRUCTION El <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST(c)I 1 HOW MANY <br /> Aodlaetlon t <br /> INSTALLATION WILL SERVE: RESIDENCE 0 COMMERCIAL ❑ OTHER 11NUMBER OF LPANO UMTS:_ M <br /> NUMBER OF BEDROOMS: ;: NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: FITfSUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANKIG REASE TRAP ❑TYPEIMFG CAPACrn / i) l NO.COMPARTMENTS <br /> c� <br /> PKO TREATMENT PLANT 1-1 ,- �)DISTANCE TO NEAREST: WELL r I FOUNDATION__!7Z` PROPERTY UNE <br /> UFT STATION❑ SIZE TYPE OF PYMPT/` SAND OIL SEPARATOR(ENCLOSED SYSTEM) - �� <br /> JJ I /• <br /> LEACHING UNE 0-0.S LENGTH OF LINFr,; 4/,�/` DISTANCE TO NEAREST:WELL.liL'I�'` UNDATION PROPERTY UNE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED C1 WIDTH LENGTHWELL_DEPTH DISTANCE TO NEAREST:WE __f0 DATION_PROPERTY ILINE <br /> SEEPAGE RTS W DEPTH R <br /> �,� SIZE _NUMBER DISTANCE TO NEAREST:WELIv� •UC O <br /> UNDATION PROPERTY UNE <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL / FOUNDATION PROPERTY UNE <br /> }DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> t. <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 REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> —SIGNED X TITLE: •e �"�®' DATE: S �®IO/IV J <br /> f ' PLOT PLAN(DRAW TO SCALE)SCALE_ 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ��!! <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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> L� 1 -- - i <br /> .. .... ' <br /> � . <br /> ch . <br /> . ...... .. <br /> .. M ... . <br /> . <br /> 2 ��e <br /> u� <br /> .. <br /> .. . <br /> .- <br /> .. _. <br /> 4 <br /> �. ... .. _ 1. ,� <br /> � .. . <br /> ` _.: ,:..�,.�:a�:•1+>.J;JIACL,L:lurafT . <br />