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SALPPLICATION FOR LIMID WASTE PERMIT AOUIN COUNTY PUBLIC HEALTH SEOCES ; ENVIRONMENTAL HEALTH DMSION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 '1 copy NON•REFUNRARtE PERMIT EXPIRES I YEAR FROM 0Ai:E ISSIIEa lcompbts in TTiplwtwl 11 1 APPLICATION I8 HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMsENTT TITLE.CHAPTER 9-1110 3 AND THE 0T/WDARb9 OF 8AH JOAOUIN COUNTY PLISUC HEALTH SEFMCES,EtkMnOMAENTALL HEALTH DIVISION. JOB ADN7RE891DR AI'N# /•✓Ky7 /,L), •t /y` A,L�.f,(/�Aell CITY �jgz��Od:' Lot ME /� - OWNER'S NAME 6o CONTRACTOR ADDRESS ''v ILC/ FHGNE I SUS CONTRACTOR ADDRESS LIC) PHONE. TYPE OF SEPTIC WOAX: NEW INsTALLAt1ON 0 REPAnUADDITION ❑ l OESTRUCTION IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEINER 19 AVAILABLE WITHIN 200 FEET OF SUILDIN0.1 PBIC TESFId I 1 NOW MANY INSTALLATION WILL MFMMt RESIDENCE❑ COMMERCOAL ❑ OTHER❑ HUMMER OF LIVING UMTS: NUMBER OF BEDROOMS: - HUMMER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKMREASE TRAP 0 TYPVMFO CAPACITY 'I,- NO.COMPARTMENTS PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION jx ":PADPERtY LINE LIFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR IENCLOSEO 9Y8TEMi LFACHING LINE 11LI NO.A LENOT14 OF NES DISTANCE TO NEAREST:WELL �� FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ' MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL L FOUNDATION PFIOPERTY LINE SEEPAGE PITS 13 DEPTH 912E NUMBER DISTANCE TO NEAREST:WELL �' FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL j) FOUNDATION PROPERTY LINE 4 OISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WEU, FOUNDATION PROPERTY LINE f '+ 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK VALL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REOVIATIONS OF THE SAN JOApUIN COUNTY.HOME OWMER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWiINO:I CER'TIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH TM9 PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANYH IN H A MANNER A9 TO BECOME SUBJECT TO WDIKMAN'9�COMPENBATION LAWS OF CALIFORNIA.- CONTRACTOR'S MfRING OR 111 BUB�ONTRACTINO SIGNATURE CERTIFIER THE FOLL NG:7 C RTIFY THAT IN T RMANCE OF THE WORK FOR WHICH TM9 PERMIT 10 18SUED,1 SHALL EMPLOY PERSOH9 SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- THE APIPCANT MUST C 2 HO S IN ADVANCE FOR AALLL..REOt11RE0 INS}PECCTTWN8. COMPLETE DRAWING BEL O W.9 D SIOFIE •r J TITLE! �.IiJ 'I�C✓� DATE:- PLOT PLAN IDMW TO SCALE)SCALE_ 'to � 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED !- 2. OUTLINE OF THE PNOPERtY,WITH DIMENSIONS AND NORTH DIRECTION. Ei(PANSION�Of SEWAGE WW'OSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, c LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH A9 PATIOS DRIVEWAYS,AND WALKS. _ THE PIWPERTY OR ADJOINING PROPERTY. .. - ' r• .. .. ............. .. V 4 .. . ... . I .. ..... . .., _. .. J i 1 >v� ...... .. ..... .... ..... .. 0e0at:59L' ;.,.. :,.. ...........: ... ...................:...... ......€..... /F�o�01PAP— OHLr APPUCATION ACDATE: +} AREA: TANK,PIT OR BUMP rNSI'ECTIOII BY DATE ! ,( FINAL INBPECTIO"BY - DATE h ADWTIONAL COMMENTS: ACCOUNTING ONLY: AID/ FAC# - ij PE CODE FEE INFO AMOUNT RENIN ITED CIRECIC/ ASH RECTSUED BY DATE SA I PERMIT NLSMBER INVOICE# t Z� n�5 1t=1-9 I � 9 E Pub.Heekh Serv.-Etrviro.174{3196} f a l