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,� a • Ar-eLICATION FOR LIOIiiO WASTE PERMIT ! SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Compkt6 In Triprmis) APPLICATION t8 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-�1)110..3j AND THE STANDARDS OF BAN JOAQUIN COUNTY R18LIC HEALTH BEFVICEB,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# !47�"E�J W-( CITY C.L� � C;4...! l �� LOT SIZE�q fes, J/ I OWNER'S NAME, Lo�.f -A`l-,o 6 �=s F'� ADDRESS PHONE Ll L k" '�l CO 0 1 ��l 0 �l/• 'p -NCrADDRESS CONTRACTOR- j 8157, F��l. .1.��J fi�iVA (—w . LiCN Z��7i PHONE SUB CONTRACTOR ADDRESS �T{ .1 l(� � Z=t UC# PHONE TYPE OF 6EPTIC WORK: NEW INSTALLATION ❑ REPAIRlAODITION D"TRUCTION ❑ "'� IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.] PERC TEST(oI I I HOW MANY Appll sdcn# INSTALLATION WILL SERVE: RESIDENCE® COMMERCIAL❑ OTHER❑ NUMBER OF UVINO UNITE: I NUMBER OF BEDROOMS: L— NUMBER OF BNPLOYMS: CHANCIER Of SORE TO A DEPTH OF S PEEP: PRI8UMP SOIL CHARACTER:._ S PI*J Q WATER TABLE DEPT} SEPTIC TANKMM"E TRAP ®TYPEIMFO_ Lx ►?T 1!.1 C�_ CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ 614 TYPE OF PUMP + $AND OIL SEPARATOR IENCLOSED SYSTEM) f LEAC14NO LINE ® NO.A LENGTH OF LINES � "" L4 O f DISTANCE TO NEAREST:WELL300 L FOUNDATION �Y�� PROPERTY UNE I C)d FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH - DISTANCE TO NEAREST:WELL FOUNDATION PIIOPERTY UNE - SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE BUMPS ❑.WIDTH 1. LENGTH 17-r DEPTH E� I DISTANCE TO NEAREST:WELL ?Q 0 FOUNDATION f�1 PnOPERTY UNE Il DISPOSAL PONDS ❑WIDTH LENOTHM�m DEPTH DISTANCE TO NEAREST:WELL -FOUNDATION PROPERTY UNE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VYD14C WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES L/AND REGULATIONS OF THE BAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWM G,.'I CERTWY THAT IN THE PEWORMANCE OF THE WORK FOR WHICH THte PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PER8PN M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR / 8UB•CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 181SOUED,1614ALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CtAUFORNIA.' THE APPLICANT MUST CALL.24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. - SIGNED X TRTLEi n• /// T '`{-'� -r��" DATE: PLOT PLAII'(DRAW TO SCALE)SCALE - 1. NAMES OF STREETS OR ROAD$NEAREST TO OR SOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ? 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF 8EWAQE 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 PATIO8.DFYVEWAYB.AND WALKS, THE PROPERTY OR ADJOINING PROPERTY. ...:.................... .. _. . .... :.. :.. .;. . ......., .. ... .. C>'.. :.:... ... ... �.. ...:.... ... y iffm ce t ... .. .. _.. .. . r ..... .l... .: ...... .. .... . . . .:......:.....: ... - � a ......... ... .... ... .. .. ....P - .,..:. r'- .. ...., ... .... .......0 ., ., .. .. .. .. .. _ ....... 0.�.... ................... � . ......... hai: N � � :.-.. . :...... . . x .. .... - ' R DEPARTMENT USE ONLY / APPL`iifhTlON ACCEPTED GY DATE: /.O -7-r!h!t_-Z:/AREt�rn TANK,PIT OR SUMP INSPECTION BY - DATE I I FINAL INSPECTION BY + DATE �! I "�t.71 J ADDITIONAL COMMENTS: � z LES � Q �^�(� �5 D sol- ACCOUNTING QNLY: ARD# FACS PE CODE FEE INFO AMOUNT REMITTED CF1WCl/MASH RE'CEr4m BY ;LATE 8n I PEFWAT NUMBET INVOICE# Pub.Heats Serv,-Enviro.174(3196)