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APPLICATION FOR LIaum WASTE PERMIT SAN-aOAQUIN COUNTY PUBLIC HEALTH SE CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420O NON•AEFUNDABLE PERM) EXPIRES 1 YEAR FROM DATE ISSUED uuu lComplete iH TrWinte! APPLICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAOtnN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDREBS101 API/ 10q'19 Sr J7i+ A!)r l rCm Q 4t?? A/ LOT SIZE OWNER'SNAME�nIn/1�Y LrC'IL��.,/I✓�1 __, ADDRESS lO 7�IF J. !!'�J��f W�/• �f PHONE CONTRACTOR_!/�f.'l�}!`J ��LAyO _ ADDRESS ) 1J g�I 'I'r -w _[IC/��-5� ��PHONE f✓-,L722 SUB CONTRACTOR ADDRESS LIC! PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION-© REPAIRIADDITION DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDINO.I PRC TFsTiol I 1 HOW MANY 1 � I , Application INSTALLATION WILL SERVE: RESIDENCE Y COMMERCIAL ❑q+� OTHER❑ ` M NUBER OF WINO UMTB: NUMBYYYYER OF BEDROOMS: -J NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: d PIT1S P pOIL CHARACTER: / WATER TABLE DEPTH ,^� SEPTIC TANKIOREASE TRAP 04TYPEJMFG Li'"C I fs CAPACITY V' NO.COMPARTMENTS `7L ` PKG TREATMENT PANT❑ DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY LINE LIFT 8TATION❑ 61ZE TWE OF PUMP SAND OIL SEPARATOR LENCLOSED SYSTEM) LEACHING LINE ❑ NO.•LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER @E D ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE i, SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE suwpB ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST.,WELLFOUNDATION PROPERTY LINE (~ DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE lJ i I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOTK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REOULATIONB OF THE SAN JOAOUIN COUNW-HOME OWNER OR LICENSED AGENT'S WGINATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN T14E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME BUBJECTTO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIAM OR SUB-CONFRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SH1LLL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION tAWS OF CALtFORNFA.;-,7"11E APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS. COMPLETE DRAWING BELOW. ' SIGNED x Z TRLE: �8rd -SI/ 'o'y,J 0-__DATE: 8 � �� 97 _ PLOT PLAN STRAW TO SCALE)SCALE 'Ro ' 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED i 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ... ... ... - .-_. _ ., --- ..., .. - . -....... _ .. _ .. .. .......1:... - .. r ;. 1...: r ............ . ... : ..........:..... :. ..................... ....: f . . .�' ., ........... :...... pu9up� wL�H :niVioN ...... . EN�IiPLQIVM1� :.....,. :.. : k :.. ......:......... i ................. ...:...... ...... I ..... � ... . , .. ...... ... � , M FOR DEPARTMENT USE ONLY y APPUCATION ACCEPTED BY DATE: / M AREA: 3 TANK,PTT OR SUMP INSPECTIONBY DATE ! FINALINSPECTION BY ATE -/ ADDITIONAL COMMENTS:�l+IRI c`� /AW LL-/ /'li ! J/ /Ns 4 /I/Y G✓ �9� �( - *c; m "01 o"k PAN rj fiOCFP ACCOUNTING ONLY: AID# FACA' PE CODE FEE INFO AMOUNT REM)ITEV /CASH RECOVIED BY Q SR I P99AT NUMBER INVOICE/ Pub,Heafth Serv.-ERvirG.174(3196) ,. f y �'