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APP ION FOR LIOUID WASTE PERMIT <br />[TfN CC}t7;4';Y pt w irr HEhT.TE1J� COUNTY PUBLIC HEALTH SERVICES <br />Sot 10hQ 110MMENTAL HEALTH DIVISION <br />�iVISION <br />1W1R0N, MFKPAL HEhLiIi iL SAI) .IOAQUIN ST, STOCKTOIii, CA 95201 -MIS <br />��� a�j 83420 <br />SPEGIE�I• „� <br />YON -REFUNDABLE PEPINT EXPIRES T YEAR FROM DATE IISUED <br />iCsmFiata is Tm Vswimmii <br />Application is hereby made to the San Joaquin County for a permit to construct and/or install the work described. This application <br />13 <br />psda <br />made in compliance with San Joaquin County Devolaent Title, Chapter 4-1110.3 and the Standards of San Joaquin County Public Nealth <br />Services, Environmental Health Division. �� <br />Job Address/ar APNS �Z� 2,� i%Gy �I'} �!F R City Lot Size <br />Owner's Ramelag=- Address_ x.7.5 f/ ^.r��t+?e�dJ $d Phone <br />Contractor Addreaa Lieu Phone <br />Sub Contractor 42, Address �r i � moi' %H L7� Lici� Pha+s <br />TYPE OF SEPTIC WORK: MESE INSTALLATION I I REPAIRiADOfTIONX QESTinicnow f 1 PEOC TESTW i 1 Naw mom} — <br />(NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 700 FEET OF BUILDIYG.) <br />Lara On AppBodaa t <br />Installation wilt serve: Rasidence_16L-' Cosaorcial Other <br />Number of living unites 4— <br />Number of bodroommr u;—Number of emptoyaees �T <br />j Character of soil to a depth 0 3 toots ,dEI!;Ar7 Ptt/Sump Soil Characters % Vater' Table Depth ,geyl�_ <br />SEPTIC TANKIBAEABE TRAP O Type/Mfg Capacity No. Comportments <br />PKC TREATMENT PLAN! I I Distance to nearest: Well foundation Property Lina <br />LIFT STATION[) Size Type of Pulp Sard OIL Separator (enclosed system) <br />IEACNMG UNE Ix Na. t, length of linesYO Distance to Nearest: Wil laudation Property Lir* <br />FILTER IED €) Yidth Length Depth " Yell Faundetl-Ae Praparty Line�� <br />MOUNDED I7 width Length Depth Veli FoudatiarL_ Property Lira !: <br />SEEPASEPIT$ Il Depth Size Number • " Uel! Foundation Property Linc <br />SUMPS Width, Length Depth //i . " Well1ti�f FoundationJQ opertY Line <br />DISIOSALPONDS €I width Length Depth " Yell Foundation Property Line V <br />I hereby cart ify that I have prepared Chia application and that the work will be done in accordance with San Joaquin County Ordinances � <br />and State Laws, and Rules and Regulations of the San Joaquin County. llama owner ar licensed agent's signature certifies the fatiawing N <br />: *I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such a ■corner as <br />to become subject to workman's compensation laws of California.* Contractor's hiring or aub-contracting signature certifies the <br />following: "I certify that in the performance of the work for which this permit is issued, i shall employ persona subject to worlman'slr� <br />compensation taws of California.* <br />The applosat won e.A1E ars is ams tat a% v miakW ibonstiaam. Complete drawing below. <br />Sisned )I� Tltle: Dater <br />PLOT PLAN (Draw to Scalel 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 diwction. proposed expansion of sewage disposal systems. <br />3. Dimensioned outlines and Location of all existing rd proposed S. Location of wells within radius of 150 ft. on <br />structures, including covered areas such as patios, driveways, the property or adjoining property. <br />and walks.. <br />1-111 DEPAQMENT USE ONLY <br />Application Accepted by C G <br />Tank, Pit or sup Inspection by Date 1 / final lnaW <br />ACCUISNTWO ONLY; I AVDO <br />PE CODE I FEE INFO I AMODUT RENUTTEO <br />FAT:A <br />RECEIVED BY I 8A7E <br />Area. -7— f L <br />SRI PEp11T WINDER I INVDICZ S <br />---7s-A 0 0 4 S !o <br />