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APPLICATION FOR 1101110 WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE,STOCKTON, CA 9SMI-388 (2091498-3470 NON-REFulitl LE PERMIT EXPIRES f YEAR FROM a E ISSUED FILE COPY (Cemplet$ In TroRe$tI) APPLICATION IS HERESY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIgq INSTALL THE WORK OtarmBEb. THIS APPLICATION 10 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.111().3 AND T IE STANDARDS OF SAN JOAQUIN COUNTY P MUM HEALTH SERVICES,ENVIRONMENTAL IMAI.711 JOB ADDRESSIOR Ar'N; V DIVISION.E. II t GQ OWNER'S NAME ''�� , CLOT S l DY car r'L -�- �'J, �.�:q //�., I (i r Aonness— CONTRACTOR jZ7`p_�f .'- .At74RF.S6 PHONE LIC; YY' C-L J~ PHONE �5 OUR CONIRACTOR ADDRESS LIC; PHONE TYPE OF SEPTIC WOR%; NEW INSTALLATION Wl RE11AIRIADDIT1011 ❑ A ^` 4UTRUCTION ❑ !NO SEPTIC SYMFM PERMITTED IF PLIRLIC SEWER IB AVAILABLE WITIRN ZOO FEET OF BUILDIN0.1 PWC TE$Ttrl I I HOW MANY INSTALLATION WILL 8FRVE: RESIDENCE.❑ COMMERCIAL SOTHER ADNIosSen! ❑ NUMREm OF ummm UNITS: NUI Illm OF eumoOMa: rr �� NUMBBI OF BWPLOYEES; CHANTER OF SOIL TO A DEPTH OF 3 FEET 2.� PtT15UMp IipFL�C-FIAIUICTER S PTIC ANKIOREASE TRAP ❑TYPEIMF 5,v,o %' CAPACITY_Ak –�WATER TABLE DEPTH - PKO TREATMENT PLANT❑ d8TANCE TO NEAREST: WELL (! l NO,COMPARTMENTS rG0 FOUNDAiION�_ PROPERTY LINE LIFI 8TAT14k�© 612E TYPE OF PUMP SAND OIE SEPAMTOR fENCIOSED 6YITTEMI LEACIINO UN£ NO.4 LENGTH OF LINES Q �i')�13 '�-- DISTANCE TO NEAREST:WELL C F'4 / f FOUNDAtFON�^PROPERTY LFNF SY CJ FILTER BEb ❑Wfb7H LENGTH DEPTH OlStphCE TO NEAREST:WELL FOUNOAt10N MOUNDED ❑WIDTH PROPERTY LINE LENGTH bEPTH DISTANCE TO NEAREST-,WELL FOUNDATION PROPERTY LINE SEEPAGE pT8 'DEPTH�-�S•F SIZE F! DISTANCE TO NEAREST'WE � `NUMRER• � uz5,,/`FOUNDATION 7D PROPERTY LINE 6UMP8 ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREBT:WELL �+ FOUNDATION PROPERTY LINE -Ir 018PpiAt PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION Yf16PEFTrY LINE TO 1 HERERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WrFH SAN JOAQUIN COUNTY ORDINANCES ANb STATE tAWB,AND RUE ES 'T AND RFOULATIONS Of THE SAN JOAQUIN COUNTY.HOME OWNER onLICENRED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE or THE 5M1 om rortmocFI tL, THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON I SUCH A MANNER AS TO BECOME SUBJECT TO WOMMAN-8 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR +l� SUS CONI CT O SIGN E CE THE FOLLO "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT t8 ISSUED,t SHALL EMPLOY I'ERSONB BtIRJECT to WORKMA 'S CO WE IO OF LIFORNIA." T A CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURED INSPECTION$, COMPLETE DRAM MPTNn BELOW. SfONFO X TITLE:_ _ DATE: _ PLOT PLAN(DRAW TO SCAM SCALE k "to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. I• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PRO SED UCt RE8 EXPANSION OF SEWAOE DISPOBAL BYSTEMS. LI S. LOCATION OF WEue WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON Tp VEWAYS,A _ i2 THE PROPERTY OR ADJOINING PROPERTY. 1� W T108 DRI — . --_ .. --G COVERED AREAS SUCH AS PATIOS, ..- .. . � .J tS r F 4. j a ,,��1 .. .. . . 138 �. . . .I� ,�z •�� .. ... .Euetz . .. r��.+ PAY M_FSR" .. . .e SAN JC A00IN r PU[LJt~E{EALJ It aLrtiliC :. A w FOA DEPARTMENT USE ONLY �'/- / / APPI.Ir,A71ON ACCEPTED RYell4/' f DATE: Z / AREA:—- TANK,PIT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY - DATES/ ajqz( ADDITIONAL COMMENTS: 11.d ,�' [/�M vc ACCOUNTING ONLY: AID/ FAC; F CODE FEE INFO AMOL/NT RF1mITED HEC /CASH RECEIVED BY DATE SR!P81MIT NUMBER INVOICE;