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APPLICATION FOR LI011iD WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HE=ALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 ROR-REFURDABEE PERMIT EXPIRES"FAR FROM DATE ISSUED lUmptata In Trlpli ate) APPLICATION IS HEREBY MADE TO THE BAN JOAOUIN COUNTY PCR A PERMrT TD CONSTRUCT ANWOR MS TALL THE WORK OESCRPEO.THIS APPLICATION IS MADE IH COMPLIANCE WITH SAN JOAOVIN COUNTY DEVELOPMENT TTTLF.CNAi7'?E09-1110.2 AND THE STANDARDS OF SAN JDAONN COUNTY PUBLIC HEALTH SERVFCES,ENVIRONMENTAL HEALTH DMI"N, JAll"B AODRE.WDR AFL I. InG Il LOT SIZE 2 DWHER'S NAME Lrfr P 4 J ADORE99� �Ll .f-a` �-'R'L r�5--nc*E' ^.�-, PHONE DONTRADTOR - lIVVIi AA iu{� +.0 ADDRESS ucfl(s�ErS.�'� PHONE 3 1-•YT7 j IE F`I _ - SUB CDNTILACTOR ADDRE69 LIC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIWADDITION DESTRUCTION❑ 1 IND SEPTIC SYSTEM PERM"TEO IF PVRLIC SEWER IS AVAILABLE WITHIN 200 FEET Of bVfLOIN i.l P@1C TFAThI l 1 HOW MANY �-�// Appllatlan f INSTALLATION WILL SIEVE: KE94DENCE Q COMMERCIAL{,Q OTHER Ia NUMROi OF LIVING UINITS: NIIMBF1t O REOR007.ta' MUNISR}!CF FMRDY6S: 1 CHARACTER OF SOIL TOA DEPTH OF 3 FEET: n PrTMUMP SOIL CHARACTER: WATER TABLE DTPTH at"I;TANR/ORILASE TRAP ❑TYFEIMFO CAPACTTY NO.COMPARTMENTS MO TAEATMEHT PLANT Q DISTANCE TO NEAREST; WELL FOVNDATMN PROPERTY UNE I LIFT STATION❑rT�SeIIE TYPE OF WARP BAND ON,SEPAIAWELL IEHCLO SED SYSTEM] r s L.CMNO VNF L ND.A 1ER46TH OF LINES 'l DISTANCE TO NEAREST: ELL FOUNDATION PROPERTY LINE FlLYE/l DEO SOWIDTH — �3• LENGTH `f'•L� OEPEH��SF DISTANCETONEAREST:WELL FOUNOATION PFOPERTYLNE , MOUNDED ❑WIDTH tEHOTH DEPTH INGTANCE TO NEARES7;WELL rOUNOATION PROPERTY VNF S®AOE FITS ❑DEPTH MZE NUMBER DISTANCE TO NEAHESTT WEll FOUNDATION P OPERTY UNE SUM" ❑WIDTH LENGTH DEPTH m DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE _ ALSPOAAL PONDS ❑WIDTH LENGTH DEPTH DU6TANCE TO NEAREST:WELL FOVNDATION PROPERTY I HEREBY CERTIFY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WOFT.WILL BE GONE IN ACCORDANCE WTTH SAN JOAOVIN COUNTY ORDLNANCEB AND STATE LAWS,AND ALINES AND REGVIATIONS OFTHE SAN JOAQUIN COUNTY,HOME OWTIERORLICENBED AGENT'$StaNATURE CERTSHEBTHE FOLLOWING;'I CERTIFY THAT IN THEPERFORI.MANCE OF THE N9r%!URONCI THIS KPMrT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON m OUCH A MANNER ASTO BECOME SUBJECT TO WOFRMAN'S COMPENBATION LAWS OF CALIFOPIRA.' CONTRACTOR'S HIRING OR 8VB.CCNTRACTINa SIONATUR E CENT0E0 THE FOLLOWING:'T CERTIFY THAT IN THE PER6OR MANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO 1 WOPKMAN'S COMPENSATION LAWS OF CALFORFlIA,' THE APPLICANT MVST CALL 2411OLRE IN ADVANCE FOR ALL REOWREO tNAP CT/IOO NS.COMPLETE DRAWING BELOW. DZGNEOX - TrTLE: ��T'� G'1-Jl DATE- PLOT PUN(DRAW TO SCAM SCAL>;_ 'I- V' � t I'NAMES OF BTRMTS OR TOADS NEAREST TO OR BOUNDING THE PFIOPERTY. •.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 7.CUTUNE OF THE PWPERTY.WTT8 DIMENSICNB AND NORTH OIRECMN, EXPANSION OF BEWAUE DISPOSAL SYSTEMS.J ].DIMENSIONED OVTVNES AND LOCATION 6F A!L EXISTING AND PROPOSED STRUCTURES, B:LOCATION OF WELLS WRNIH RADttJ6 OF ONE HUNDRED FIFTY FT. ON \ IHCLUOINO COVERED AKAR SUCH AS PATIOS,DRIVEWAY",AND WALKS, THE PROPERTY OR ADJOINING PFOPERTY. `.- ?�r . o c ...:.. .... - - f - - . .. '. ISA Y6Y1�tV I ...... ...... :.... :R ECE LV IW ...... FEB E -- ---`... AIJ� NI PUBLI r a ............ ENVlyONMc LTH 5ERV1!E5 _ _ _ - .,. ..., EN7Fy-HEALTH 1 1 G .,SA r`. _. ..... FOR DEPARTMENT LISS ONLY APPLICATION ACCEPTED BY DATE: �-r _V"— ARFA: AHK,PE OR BUMP FYC7 N BY DATE 7 ! FINAL M1HSPECTION BY DATE ADDITIONAL COM HT .=I� W c- f 1 x r 3 F} I k 2.! frl rl xkt 1 or. ACCO"n%NO ONLY: ND.I FACS 1-.. PE COOS TEE INFO AMOUNT REAR PTSD CHEC%/ ASH RECFF F SAY DATE M E PERMIT NUMBER INVOICE F Pub.Heahh So,.-EDYirD.174(3M) t