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3�y APPLICATION FOR LIQUID WASTE PERMIT <br /> i SAN JOAQUiN COUNTY PUBLIC HEALTH SERVICES _I <br /> ENVIRONMENTAL HEALTH oIVISION SCANNED <br /> 1 <br /> P.O.BOX 388,446 N.SAN JOAQUIN ST,STOCKTOCKiON,CA 96201.0388 <br /> (209)468-3420 1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU ED application <br /> Il <br /> ICeiaPMta is Tr4kate) <br /> Application is hereby made to the San Joaquin County for a pe <br /> wait to construct and/or'install the work described.otii Y Pubs c Health <br /> is glade in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin `Z <br /> Services, Environmental Health Division. City L( Lot Size_�_� <br /> CA- <br /> Job Address/or APN1t 3z �JA � <br /> 147 0�f E f-�f(if-{C��'y Zf,� LIN D� 9ri 23� Phone 8 �'� <br /> ^�,,,rt ��,rngyi Address q43-ZcZI <br /> Owner's Name t- �' r�g���p Lict��Phone__ <br /> slf{��1� ejY,1)IF.�- MC1 (Address'fOC{ <br /> Contractor LicA— Pho <br /> Address <br /> Sub Contractor DESTRUCTION II PERC TESTIeIIeNow an <br /> pFPAIRJAODITI0Ml1 s-1 _3C <br /> TYPE OF SEPTIC WORN: NEW INSTALLATION II Land Use APPIKatMa <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) <br /> Camlercial_ Other_ l 409 � , <br /> Installation will terve: Residence__ Nurber of emploYeee: G T4" <br /> Nrml»r of living unitar__ Number of bodroomar_ Pit/sung$OIL Character:_Water Table Dapth_!�r <br /> Character of soil to a depth of 3 feet[ Capacity No, compartiente <br /> SEPTIC TANKIGREASE TRAP 17 TYPO/Mfg Foundation Property line <br /> PKO TREATMENT PLANT [ ] Distance to nearest: Well <br /> LIFT STATION[] size__Type of Puitp send Oil Separator (enclosed system) — <br /> LEACHING LINE [] No. 8 Length of lines Distance to Nearest: Well Fotrxlation Property Lime 6 <br /> FILTER BED UWidth Length Depth <br /> " Well Foundation Property Lin <br /> U <br /> �� Well Foundation Property Line_ <br /> MOUNDED [] Width Length De <br /> SEEPAGE PITS ❑ Depth_Size N r fi e Well Foundation Property line <br /> CQ &¢ it , Fourdation Property Line (� <br /> SUMPS [] Width_Length Dept a9 \ <br /> �((Illj i, �e ( urdatior Property Line <br /> DISPOSAL PONDS [1 Width Length DWJhhr may al�g <br /> I hereby certify that I have prepared this applil'i}ption qr W .dp/j¢�accordance with San Joaquin county Ordinance <br /> and State Laws, and Rules a Regulations of the�t33..KKnnrJ,¢ }na our.`-tiS/�i�I weer oorr•rf agent s signature certifies the following <br /> "I certifythat in the performance of the work for w is t i is sub all not employ any person in such a manner as <br /> to become subject to workman's compensation laws of California." C �b� �rT 4,���r sub-contracting signature certifies thc( <br /> following: "I certify that in the performance of the work for which this pe r{n'ftU�:�l3fi}le�, I shell employ persons subject to workman' <br /> VI' <br /> compensation laws of California." <br /> ,M The applicant mu.t ohour.In advance for all raqu4ad Inaputiona. Complete drawing below. /� <br /> Signed X f _ i✓• <br /> Title: "r(41'-'+J1 Date; CP-27 5 <br /> 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 <br /> 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and Location of ell existing and proposed 5. Location of wells within radius of 150 ft, or <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> k n I r, <br /> 3 ( <br /> e ( .sat <br /> _ l _a _ilx <br /> I W J <br /> Q LLf <br /> g cp <br /> ter I <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by x, -LInspection <br /> e: -L- 1 `I Area: <br /> Tank, Pit or Scarp Inspection by -c� Date Finalby Date <br /> Additional Comments: q t,I <br /> ACCOUNTING ONLY: AID# <br /> PE CODE I FEF INFO AMOUNT REMITTED HECK ICASH I RECEIVED BY I DATE SR I PERMIT NUMBER INVOICE <br />