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APPLICATION FOR LIRUIO WASTE'PERMIT PAY NT SAN JOAOUkF"``�UNTY PUBLIC HEALTH SERVICES j ENV( 'RENTAL HEALTH DIVISION REG =D JI- 304 EAST WEBER AVENUE,STOCKTON,,CA 95202 NOV 8 2000 (209)468-3420 O I E UgFlAMffjVI9f9 I YUR FROM VAIESAN JOAQUIN COUNTY �", {gMpNu in hylliuui P€1BLI�I�CIF LHIttE��A��m�i S�SpEWICES APPLICATION 18 NETIFBY MAGE TO THE SAH JOAOUIN COUNTY FOR A RPPAIT TO CONSTPLCi ANDAPII NfTALL THE WORK DEBCPJBEb.TARS AlTVCATgN U L`'BgI�UANCEI';gITION JOACUIN COUNTY IIEVTLOPMENT TITLE.CHAPTER 9.1110.3 AND THE BTAIDARDO OF SAH JOAOUN COUNTY PUBLIC HEALTH fEM1VICEI,ENVIRONMEMAL HEALTH ONI ON. I .FDS ADDREBaGR APNO 5506 W, )l r— Cm 1 LOT Inze yy o0Cs'lej OWNER'S NAME $1"LA wl'� f�✓{�'IU F ADOMBS �^ �F (� PHONE y -73 2 . COMRACTOR V{'j,N M e[�41 E fZ_ ADDRESS_ StJ U�' w r 4 r-y{Jt BUB - UCA 3 7/3�6 F410NE;2h ��a 7 i CONTRACTOR I ^^ AGGRESS /��Q/� _ �u11.�1 al`,k�^ RHONE I TTPP OF SERIC WORK: NEW INETA[LITION ZZAIADDITION❑ MTRUCTION❑ r CIO SETRM:SYSTEM PUNIRRED IF PUBLIC SEWER li AVARABL[1MTNIN TOO FEET OF BVRDINOJ MIC TEfTh11 I HOW MMT F ' APPErNw f { INSTALLATION WILL J40Mi REBIOENCE I( COMMERCIAL❑ OTHER El NUMSIM OF LIVINO UNITS:NUASM OF BEDRODMNUMBER UMBER OF IM OvIlls: CHARACTER OF POR TO A DEPTH OF J FE7'T:'J/' RT)N,A/p SOIL CSN R; WATER TABLE DFPTN 2S 'W"C 1ARIVO LUF TRAP ❑TYPEIMPo C./�fi'�I L T"r gAF lry NO.COMPARTMENTS '.�. 7 Pc0 TMI'MTNT PLANT❑ DISTANCE TO NEAFIMT: WELL S vD I FOUNDATION RgFFRTY LINE y Z.Ste` y LIFT STATION❑ SDE TYPE OF PUMP' BAND OR SEPARATOR IENCLOSE)SMtMI�.y''�` q LEACHING LINK CFNO.SLENGTH OFUNEi _C geTNiCETONEAReTtWELLFWNlMT10N / PROPERTYMHE_ Y9r FILTER BED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL T FOUNDATION PROPERTY UNE FjMOUFIPFD 10 WIDTH LENGTH ' DEPTH DIQTANCETO FIARE9TI WELL FOUNDATION PROPERTY UNE OEEPAGI RTE f3 omt RT SI NUMBER DISTANCE TO HEAREBT,WELL FOUNDATION PROPERTY LINE PUMPS ❑WIDTH LENGTH DER" DISTANCE TO NEAREST,WELL - FOUNDATION ' PROPERTY LINE -- DISPOSAL PONDS ❑WNITH L ENGTH DEPTH DISTANCE TO NFAFESTI WELL 'FOUNDATION PR OPERrYLNF I ' rI4 - I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WDRPC MILL BE DONE IN ACCORDANCE MTN SAN JOAOUN COUNTY OPIONAHCEi AND STATE LAWS,AND RULESAND REOUTATION9 OFT11E BANJOAOVIH COUNTY.HOMEOWNER DRUCENSEOAGFMT'S SIGNATURE CERT8IES THE FOLLOWING,9CERTIPYTNATNTHEPILWOMAICE OFTHE WOFKfOAWKKH THIN PERMIT IS ISMIEO,I SHALL HOT EMPLOY ANY PERSON N SUCH A MANNER As M BECOME NUJECTTOWORKNAMi COMPENSATION LAWS OF CNAOIWIA.-COMNACTON'miNnNO OR fUEPCONTRACTNG Bq NATURE CERTtPEi THE TOLLOV NG;'1 CERTIFY THAT IN THE FEIYORMANCE OF THE WORK FOR WIOCH THIS PERMIT U(ISMO,I SMALL EMPLOYPERPONS 8U8JECTTO WORKMAN'B COMPENSATION LAWS OT CALHFORNPA.'.THE APPLICANT MUST CALL N HOU S IN ADVANCE FORRIAtL RfOLI111FD,DIN'EOTIONS.COMPLETE DRAWING PEL.11W, -T INCHED R C ~ - TITLE:( DATE:-�l/'/y•�/fid G7 . PDT FIRN OPLAWTo BCAIfl 1.NAMES OF STFEETf OR ROADS NEAREST TO OR SOUNDING THE PROPERrY. S,LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 7.CLOTURE OF THE PROPERTY,WITH DIMENWONP AND NORTH DIRECTION. EXPANSION OF SEWAGE DIFOWMf. SSAL STE O.DIMENINONED OUTLINES AND LOCATION OF ALL EEINTINO AMD PROPOSED STRUCTUPEi, S.LOCATION OF WSLLf WITHIN RADIUS OF ONE HUNDRED PFT/FT.ON NDLUDIFIO COVERED MEAS BUCH AS PATIOS.DRIVEWAYS.AND WAIX8. THE PROFERTY OR ADJOI RIIO PPOPERRY. - .. ..'... r.. : g Fl SSP . ...... . ................. r-q- -s�................ .......L ..... ..... J .1... ................ ........ ............. 1 (Q "'j 'i ............... I.... .4 �f .... ......4 . ......�L . ...... Y 7. i ................ ...... ......... ....... ......... ..... ............. f ......... .......... ... g ...... ....... f+ .. iOR DtrMTIAnT U&I ONLY A^PPLICATION ACCEPTED BY_ 1VIJAI 4\IYM1LSKA�.'�. '�'/C-71 DATE; — V PIT OR BUMPIHBPFCTICN BY I DATER.1 /.J IAV FINAL INSPECTION ADDITIONAL COMMEMB'_ FACCOUNTING ONLY: ADf PACT p ot coalK COOS FEE INFO AMOUNT RMN$TLO CIHECKOOC H RECEIVED BY DATE ARI PUMTRUISITI INVOICEF i Pub.HBltkh SGrv.-Err/in).174(W) - Fi Fil I