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APPLICATION FOR 1.1111110 WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �4 6 ENVIRONMENTAL HEALTH DIVISION ,'fa 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (249)468-3420 l' NON•REFUNDAM PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ii G—pl-IR in Tripli-.1.1 APPLICATION 15 HEREBY MADE TO THE BAN JOADUIN UOUHTY FOR A PERMIT TO CONSTRUCT ANDAR INSTALL T11E WOTK OEgC WBED.THIS APPIICA74ON It MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTEq 91110.E AN'T TANDAl1D8 OF HAN JOAOVIN I'll WELIC 1111TH SERVICED.ENVIRONMENTAL HEALTH DIIBION, Jae ADa1LEssroR AE'N. (,�(,,{J/ �I 1 cITY Il/9/C ��- 1 G LOT 6IZ"E� I k OYMER'9 NAME A j A }'1 ADOMS9 (/ / I L,C'-�r PHONE z -'J 1 + CONTRACTOR \ 1-, AUvRFSS 76�•J L1CI PHONE 7 i f _ [.. DUG CONTRACTOR AODPESS UC/ {'HONE TYPE OF SEPTIC WORK: NEW INSTALLATION gIBTAIWAODIIIOI (`/`7p 1� DEITn DCnON❑ " F !ND SEPTIC SYSTEM PERMTTTEO IF PAIBUC SEWER 16 AVAILABLE WITFIIN 2Dp PEST DFJBIIItpING,I/� PBIc TEST Id I I NO=MANY L AP MwNon F �[ INSTALLATION WILL ESw E: RESIDENCE❑ CGMMEMI-4 OTHER —a-OF ITIHG UFRTE: N-G-OF 0-0-17NlIAE GR OF EM OY6JI: fl` CHARACTER OF SOIL TOA DEPTH OFF1-y3 FE[T;�yQ —C>17 >C/l RITfSUMP SOIL CHARACTER: s, WATER TABLE OERFH IEPTIC TANIUMEASE TRAP LJ TYPES PG f!*L CADACTTY �7C-C/'Dl7NO.COMPARTMENTS� FKO TREATMENT PLANT[I INSTANCE TO NEAREST: WELL_ 11 FOUNDATION Vt-,,�7- PHOAEIT Y LINE /y/�r UFT STATION© SIZE TYPE OF PUMP SAND OIL SEPARATOR{ENCLOSED SYSTEM; LEACHING LINE ❑ NO.B EENOTH DF LINES DISTANCE TO NEARREET:WELL FOUNDATION PROPERTY UNE 1 RLYp18ED YVIOTH� LENOTN /(� DEPTH 7R>�/DISTANCE TO NEAREST:WELL�!/��r FOUNDATION T�/ PgppERTY LINE MOUNDED ❑WIDTH LENGTH -�DEPTH //CJS DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FETAAOE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:YYLLL FVUNDATION PROPERTY LINE 6UMFE ❑T-I WIDTH LENGTH DEPTH DISTANCE TO NEARERT!WELL FOUNDATION PIROPERTY UNE LJ [ M&POSAL PONDS WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROFEITI'Y LIRE I HEREBY CERTIFY THAT l HAVE PREPARED THIS APPLICATION AND THAT THE WOM WILL BE GONE$N ACCORDANCE WRH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWD,AND RULES AND REGULATIONS OF TER£BAN JOAQIIIN COUNTY.HOME OWNER OR LICENSED AOENT'B SIGNATURE CERT IFIEB THE FOLIDWING:'I CERTIFY THAT INTHE PLHFOIRIAHCE OF THE NAPK FOR WHICH THIS PERMIT IS ISEVED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A9 TO BECOME SUBJECT TO WOFKMAN'S COMPENSATION TAW!OF CAUFORNIA.-CONTRACTOR'S MIRING OR DUB CO NTRACT0,10 WONATURE CERTIFIES THE FOLLOWNO"I CERTIFY THAT IN THE PEF FMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO MWMAN'S COMPENSATION LAWS OF CALIFORN IA.' THE APPLICANT MU-T CAU,IA HOURS IN ADVANCE FOR q/)ALL �REEGUIRED INNSPECTIONS, COMPLrrf DRAWING BELOW, f SIGNED A F_ = 'r .r.�J, 'C-4 iTTIE� JET Ei DATE: -7 V - PLOT PLAN IDRAW TO SCALES SCALE �L7' 'to L 1.NAME&OF STREETS OR ROADS NEAREST TO OR LOUMDINO THE PROPTFOY. 4,EQUATION OF NOV6E BEWAOE 016POB L SYSTEM OR PnOPPEED 2.OVTUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH INFECTION. EXPANSION OF SEWAOE MOPOBAL EYSTLTAB. r ].DIMENSIONED OUTLINES AND LOCATOR OF ALL EXISTING AND PROPOSED STRUCTVREE, S.(DCATIOR OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT,OR INCLUDING COVERED AREAS SUCH AS PATIOS,DPIVEWAYB,AND WALKS. THE PROPERTY OR ADJOINING P PENTy, .... ..... .. .,. _ ..... ..,... . ... 1 13a♦ dfi(/C _ ,. 7 .-....... ... . 4ie1.vim' ... .. ...,. PTE Ci: dVED ....... f� ;. ;.. a 1 .. - 1 FOR DEPAFTMENT USE ONLY T APPLICATION ACCEPTED BY DATE: AREA:_ TASK,PTT OR SUMP INSPECTIO BY DATE I I FINAL INSPECTION BV PATE 102 d ADDIrrorlaL CGMMENT s:�o iwh.EE'!FI L S ST�ay 1'S 6 -R S JC/oor� NEL LSE a Q cl w rEz- Fyu G - cfDnJ R� .5-22 7ao0 user, 8F %B t/An LsEI� I ACCpVNTTNO ONLY; ADI FAC/ A7- So k7K CrAlP� PE CODE fEE;NTO AMCVNT REMIITED HEC ICASH RECEIV©BY DATE 9R IPEpMTNUMBIR DNOICES 1 15 25-n Pub.Hoeh SON.-Envim 174 I3/9aI