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APPLICATION FOR LIOU10 WASTE PERMIT NN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9S20i-388 (209) 488-3420 �-}- ON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATS ISSUED EF"ENT 3Mempkts In TriplkatdArrHCATION IS HFREBYO THE SAN JOAnUIN COU TY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WRII SAN JOAOUIN COUNTY 01-VE TFTLE,CHAPTER 9-1110..3 AND THE STANDARDS OF SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# / J �' Oz� Z CMY_- � _ _LOT SIZE OWNFR'fi NAME ~� �G ti7J'�-,/ ADORERS L2 L�- S �_ �ll nr �� `PH/ONE 15 36-cz- CONTRAF:TOR G/) AbbhFRS f`/J �L� LICK ' /�•��;G 44/ 10NE '!2 Pee_ ��^+ SUB CONTRACTOR AODRER9 LIGE PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ _ IMO PEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 2(10 FEET OF BUILDING.) PFRC TERT191 I 1ff HOW MANY z INSTALLATION WILL SERVE: RESIDENCF ❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF UVTNO UNITS: NUMBER OF BEDROOMS• NUMBER OF EMPLO YEE6: CVfARACTEA OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANXIGREACE TRAP ❑TYPE/MFO CAPACITY NO,COMPARTMENTS MEG TREATMENT PLANT ❑ DISTANCE TO NEAREST; WELL FOUNDATION PROPERTY LINE UFT STATION❑ C17F TYPE OF PRIMP RANO ORI,SFPARATOR IENCLPSfD SYSTEMI LFACHINO UNE ❑ NO.k LENGTH OF LINES DISTANCE TO NEAREST:WELt FOUNDATION PAOPE1TTY LINE FILTER OFD ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FnUNDATTON PROPERTY LINE MOUNDED ❑WIDTH LENOTH DErTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PIT@ ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINf SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DI@POSAL PONOS ❑WIDTH LENGTH DFPTH DISTANCE TO NFARFST:WFLL FOUNDATION P"OPERTY LINE - I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK HALL BE DONE IN ACCORDANCE WITH MAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND Rl1lFS AND RFOULAT IONS OF THE BAN JOAOUIN COUNTY.IID ME OWNER OB LICENSED AGENT'S SIO NAT VRE CERT INES 7 HE FOLLOWING:'I tETTTIFY THAT IN THE PERFORMANCE OF T HE WORK FOR WIIICII THIS I`ERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUR-CONTRACTING SIGNATURE CERTIFIES THF FOLLOWING: 'I CERTIFY THAT IN TIRE PFRI'ORMANCE OF THE WOW FOR WHICH TH19 PERMIT 19 ISSUED,t SHALL EMPLOY PERSONS RURJF.CT TO WORKMAN'S COMPS ATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTION@. COMPLETE DRAWING BELOW. / r� SIGNED X /� .- TITLE: ✓ � !�- /7'" c.`'' _ y I�yJ I DATE'--/dP -11T.- PLOT 11T -PLOT PLAN(DRAW TO SCALE]SCALE le 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SFWAOF DISPOSAL SYRTEM OR PROPOSED 2. OUTLINE OF THE FTIOPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF @FWAGF DISPOSAL SYSTEMS. 7, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELL@ WHHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATFOR,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 733 : BMs - 93- �I t p r Pyw1-I� I off ? 3/Y'I Row- QF r OCT 1. 3 ]997 sB PU CFfA1vi1U1N ` ERitUlF}ONA �,L7F 4 �i1�r,,�,}�:•, ,� FOR OFrAhTMFNT U61F ONLY Arri ICAIION ACCEPTED BY 4 tC/ IJ DATE: •�:2 AREA; TANK,PIT OR SUMP INSPECTION /t DAT F, I I FINAL INSPECTION BY L DATE l0 / /y I 7 A001tIONAL COMMENTS: ACCOUNTINO ONLY: AID# FACT rt conE FEE INTO AMOUNT REMIT IE.D HEC YCASH RECEIVED BY DATE SA!?ET MIT HURN80t INVOICE 9