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APPLICATION FOR LIQUID WASTE PERMIT _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-0388 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IC,mpi,n in Tripliuft) <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APRICATON IS MADE IN COMPLIANCE NTTH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TIRE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH �VIIC�E,B,�E�NVrIRONMENTALAL HEALTH DIVISION. �./���,� <br /> JOB ADDRESSIOR APIJE CT' znt �M1�'ITw 1 LOTCSIZE _9'1 Vs'�'� <br /> /i Y�/1 'AwO ADDPESSI / ga <br /> > � PIIONE�Ia-kX�'G6S.2 <br /> OWNER'S NAME �({//y���'-y/•/17 <br /> / �• <br /> CONTRACTOR !1 -KICADDRESSL� I -� UCE�%l'2S�Z7..6 P110NE <br /> SUBCONTRACTOR ADDRESS mo- <br /> UCF PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPARVADDIT N ry DESTRUCTION <br /> IND SEPTIC SYSTEM KWR EO IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PIM TESTol 1 I NOW MANY <br /> Apµaetlon J <br /> INSTALLATION WILLSERVE RESIDENCE COMMERCIALE3 OTHER 13 <br /> NUMBER OF WINO IT,: NUMBER OF,BEDROOMS:�NIRA,6t OF EIRPDYEE,: <br /> CHARACTER OF SOIUNL TO A DEPTH OF,�-3JFEET: I'J L-a�1 PTFSUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANKIOREASE TMP RIO TYPE/MM RA/J E'S CAPACITY I(P OO NO.COMPARTMENTS n.A. <br /> PALO TREATMENT PANT❑ DISTANCE TO NEAREST: WELL io , FOUNDATION IQ / PROPERTY ME�� <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) / <br /> E <br /> LEACHING ME �NO.,IFJVIITH OF LINER d � 9®� DISTANCE TO NEAREST:WELL�1 FOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SEEPAGE PITT DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SUMPS WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> DISPOSAL POND, ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE (� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OVINEROR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THEWOPR FOR WHICH <br /> THIS PEWIT 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 /> SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF�C(AUMFNNIIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL MODIFIED IN,PECMN,. COMPLETE DRAWING BELOW. <br /> SIGNED% �^RI N /[ TITLE: �e_" DATE: <br /> T RAN(DRAW TO SCARE)SCALE 'H <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 3. OIITUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF AUL AND PRGNSED STRUCTURES, B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> LL EX <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. .11 <br /> ct, 110 <br /> o � I f <br /> 11 U <br /> JUN 2 9 1995 <br /> LRVICES <br />