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q 111 � I 15�-✓ APPLICATION FOR LIO.UIO WASTE PERMIT �IDA SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � ENVIRONMENTAL HEALTH DIVISION 304 EAST WEEDER AVENUE, STOCKTON, CA 95202 { " ,4,"�1, 1&/,? (209)458-3420�' " q�,l N08•REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED �i (Cempinte in Trip1'matn} APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMT T IO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CH TAMER 9-1114.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. ^i+ LOT SIZE JOS ADDRESSIOR APN/ OWNER'S NAME I ADDRESS // Q BdX /9 C Am!'wLL -- _ PHONE 759-.3/81 CONTRACTOR I� ADDRESS - LIC) PHONE ! PHONE SUBCONTRACTOR ADDRESS LICI TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUC 1, i POW TESTNT I I HOW MANY INO SEPTIC SYSTEM PERMITTEO IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDING.) APPNwtlo-0 A INSTALLATION WILL SERVE: RESIDENCE© COMMERCIAL ❑ OTHER❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUIMS94 OF EMPLOYEES: ' 1WATER TABLE DEPTH .CHARACTER OF SOIL TO A DEPTH OF 3 FEET:' PTISUMP SOIL CHARACTER: 1 SEPTIC TANIDGREASE TRAP ❑TYPEIMfO CAPACTrY NO.COMPARTMENTS 1 ^^�Y I PROPERTY LINE IJ PKO TREATMENT PLANT DISTANCE TO NEAREST: WELL FOUNDATION LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) i LEACHING LINE ❑ NO.8 LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL - FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH , LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SII SIZE NUMBER—'DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BUMPS ❑1MDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE u DISPOSAL PONDS ❑WIDTH i= LENGTH DEPTH DISTANCE 70 NEAREST:WELLFOUNDATION PROPERTY LINE I 1 HEREBY CERTIFY THAT I HAVE PREPARED TH18 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUtN COUrTTY ORDINANCES AND STATE LAWS,AND RULES AND REOULATIONSOFTHE GAN JOAQUIN COUNTY.HOME OWNER 09 LICENSEDAOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'ICERTIFYTHATINTHEPERFORMANCEOFTHEWORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES T%HE FOLLOWING:'1 CERTIFY THAT IN THE PEFtFOFIMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WGR KMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURIED INSPECTIONS. COMPLETE DRAWING BELOW. 1 SIGNED TITLE: /1f/1// DATE: 7-1 959— PLOT pPLOT PLAN(DRAW TO SCALE)SCALES "to i1 1. NAMES OF 8TFIEEI S OR ROADS NEAREST 4TO OR BOUNDING THE PROPERTY. 4. LOCAMN OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED `- 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. , EXPANSION OF SEWAGE DISPOSAL SYSTEMS. } 3. DIMENSIONED OUTLINES AND LOCATION SOF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PRDPEHTY. . .. .... ' r - : ' - . ... ..-...- .... ....... .. .. .. 4— E J. /rc �1sTii�rs ...,f _ S.'.L :� T . NVIRC?N�,1�t,r4l,If�_� w..... ........ ......._ Q....-......,..... .... t '. DQ ' 4_ ...�� 1` .. ., ...... .......,..... '�--++s• �..z,.w-.r--„��:-.rw.-��.s-4 .. _ .�-: -ti,e.t.=.:. - -.�.,e+Gr,.,..,...g�r�... ........^�.� ...... ......... ...;.. .... .... .. .... .... ... I FOR O MTTMENT USE ONLY C (/ f 1 APPLICATION ACCEPTED BY ! DATE: AREA:�4 2 + 1 ` TANK,PIT OR SUMP INSPECTION SV I BATE ! ! FINAL INSPECTION SV �� pA7E ADDITIONAL COMMENTS: I: I ACCOUNTING ONLY: AIDE FAC.) , PE CODE FEE INFO AMOUNT)REM)ITED CHEC ASH RECIBVED BY DATE. SRI PERIY-T NUMBER INVOICES '7 u t r Pub.Health Sere.-Erlviro.174{3/96} ` { � c-fi