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<br /> i 1APPLICATION FOR LIQUID WASTE PERMIT
<br /> SAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES'"'
<br /> { 1 ENVIRONMENTAL HEALTH DIVISION
<br /> P.O. BOX 3881 SM EAST WEBER AVENUE,STOCI( ON, CA SMI-M
<br /> (209) 468.3420
<br /> NON-REFUNDAKE PERMIT EXPIRES I YEAR FROM DATE ISSUED FILE COPY
<br /> (Cemplate In Triplkat6]
<br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION I$MADE IN COMPLIANCE WITH SAN
<br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.
<br /> f' JOB ADDRESSIOR APN#� .�0. _,�,(/ ULe't)P,11!. YAC_. CITY, ,xyc�i. LOT SIZE
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<br /> I OWNER'S NAME%�'I.LsS. .I'-1n( ADDRESS PHONE - 6
<br /> CONTRACTOR-�P��r�:. ,LjlJrif ADDRESS 165/p LIC# '1C90ey ` PHONE1117
<br /> SUB CONTRACTOR ADDRESS LIC/ PHONE
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlADDITION S DESTRUCTION ❑
<br /> � (NO SEPTIC SYSTEM PERMITTED IF PUBLIC StWER IS AVAILABLE WITHIN 200 FEET OF BUILDINO.I PWC TESTIS)I I HOW MANY
<br /> Application S
<br /> INSTALLATION WILL SERVE: RESIOENCE'5 COMMERCIAL ❑ OTHER ❑
<br /> NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS: '� NUMBER OF EMPLOYEES:
<br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: `5/jgkIL PITISUMP SOIL CHARACTER: WATER TABLE DEPrH <D-
<br /> SEPTIC TANK/GRFASE TRAP ❑TYPFJMFG CAPACITY NO.COMPARTMENTS
<br /> PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE
<br /> I LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM)
<br /> LEACHING UNE G--NO,i LENGTH OF LINES (7UlinfAY' !,V_ DISTANCE TO NEAREST:WELL 'S` FOVNOATH)N��PROPERTY UNE S�s
<br /> I FILTER BED E3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> I MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> SEEPAGE PITS ❑DEFTH SFZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE
<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 AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:"1 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 l'Jy
<br /> III 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 tat
<br /> i+ WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 NOULG IN ADVANCE FOR ALL RROURED INSPECTION$. COMPLETE DRAWING BELOW.
<br /> i STONED X _ TITLE: &aZC L_= DATE: )OATA7 -
<br /> PLOT PLAN(DRAW TO SCALE)SCALE 'to -
<br /> I 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 ADJOININO PROPERTY. m
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<br /> ' FOR DEPARTMENT L18E ONLY
<br /> APPLICATION ACCEPTED BY DATE: / Z-' .?
<br /> TANK,PIT OR SUMP INSPECTION BY ♦ DATE I FINAL INSPECTION BY DATE, �u 123 1 Y7
<br /> ADDITIONAL COMMENTS: E t: C h ✓
<br /> ACCOUNTING ONLY: AID# FAC#
<br /> PE CODE FEE INFO AMOUNT REMITTED CHECK# ASH REC ED BY DATE $R 1 PERMIT NUMBER INVOICE#
<br /> €,
<br /> 6941.2 ao0
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