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' 1 <br /> APPLICATION FOR LIQUID WASTE PERMIT <br /> _ - SAN.fOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 1 <br /> NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 1# i ;Cimpliti In TTiprKatil <br /> E APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED- THIS APPLICATION IS MAGE IN COMPLIANCE WITH SAN <br /> �AOUIN COUNTY OEVELOFMENT TITLE.CHAPTER 0-1110.3 AND THE STAND AN BAN JO OUIN COUNTY PUBLIC HEALTH SERVICES.EWMWNMENTAL HEALTH DMSKIN. ,��/r1 <br /> �� 1111 CRY AL1_! LOT 8IZ f�L.` e- <br /> JOB ADORESSIOR APN ��111..����rrr �{ <br /> i U1 <br /> y ADDRESS PHONEER' <br /> OWNS NAME ICT_ <br /> CONTRACTOR <br /> C1 ADDRESS PHONf �j <br /> LIC# PHONE <br /> 6U6 CONTRACTOR ADORES6 . <br /> ! <br /> i <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 0 <br /> ., FERC TESTIU i I NOW MANY <br /> ING SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET Of,BVIi_DINd.I <br /> i <br /> AppYilowm# <br /> INSTALLATION WILL SEINE: RESIDENCECOMMERCIAL❑ OTHER❑ i /�qt <br /> NUMBER OF EMPLOYEES: l•��`Aj —lam i j..I'�?i s.,"'-t•� <br /> NUMBER <br /> OF LMNO UNITS: NU1YI66t OF BEDROOMS: NUMBER �-} �,•.,�l 1:Ty y.z., �.�� <br /> SOIL TO A DEPTH OF 9 FEET: PIT/SUMP SOIL CHARACTER• l�''TER`t:4gLE OE>�H j <br /> CHARACTER OF I ._t �u ,V <br /> SEPTIC TANKIOREASE TMP ❑TYPEIMFO :'CAPACITY ���••JJ��- - <br /> sFOUNDATION PROPERTY LINE `. <br /> pK0 TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL. "'` <br /> I <br /> LIFT STATION❑ S¢E TYPE OF PUMP SANG OIL SEPARATR(ENCLOSED SYSTEM) <br /> 1iDIBTANCE TO NEAREST:WELL -FOUNDATION PROPERTY LINE <br /> LEAC14NO UNE ❑ NO.i LENGTH Of LJNE6 I <br /> RLTER BED [3VNDTH LENGTH DEPTH i DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> :LI DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED '❑WIDTH LENGTH li DEPT" <br /> dEEPILOE PITT DEPTH an / NUMBER i DISTANCE TO NEAREST:WELL 1. FOUNDATK7H� !L 1'ROPERTV UNE <br /> LiUMPi ❑WIDTHLENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS I' ❑WLDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I,HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOFK+WILL BE DONE IN ACCORDANCE WITH SAN JOAOUiN COUNTY ORDINANCES AND STATE LAWS.AND RULES <br /> L AND REGULATIONS OFT14ESAN JOADUINCOUNTY.HOME OWNER ORLICENSEDAGENT'0SIGNATURE CERTIFIES THEFOLLOWtW!ICERTIFYTHATINTHEPERFORMANCEOFTHEWORXFORWHKH <br /> r1i18 PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUSACT <br /> TO WOIKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S H SUBJECT <br /> OR <br /> SUB-CONTRACTING'SIGNATURE CERTIFIES THE FOI.LOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISBUED.1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S PENSATgN LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOU✓yR$IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAYM40 BELOW' <br /> i I � O <br /> L <br /> ! K �.J TRIP. DATE•, SIGNED x -.. <br /> PLOT PLAN(DRAW TO SCALM SCALE •ro <br /> <. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OA PIKOF'OSEO <br /> LTHEF STREET'S OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. i LOCATIONEXPANSION F SEWAGE WAGEDISPOI SYSTEMS•2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. ! 6. LOCATION OF WELLS 1MTHIN PAWS OF ONE HUNDRED FIFTY FT.ON <br /> DIMENSIONEDOUTUNES AND LOCATION OF ALL EXISTING ANO PROPOSED STRUCTURES, A OR ADJOBrING PROPERTY'INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. :i !e <br /> .. .. <br /> 1 � <br /> ... <br /> i. <br /> i <br /> :... .. <br /> I <br /> ... ..... .... <br /> ... <br /> .. <br /> + . . . <br /> L : .. m <br /> PAYIVIEUT : <br /> OCT 7198 <br />