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APPLICATION FOR LIOUIO WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.U. BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 96201-0388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lComplata In Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3/AND THE STANDA S OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,EN/VIIFOlN+MENTAL HEALYH DIVISION. JOB ADDRESS/OR APNA' .,r' �(.r Y' ! L� CITY.. �U CD l\. i"o't _ _LOT SIZE 1 L OWNER'S NAME jj r 1-(L IR C /( �c 1 /`��' 1 4 E'AD RESs ff . PHO Ne , Jr5J' CONTRACTOR' J-JO II`. D H Oei-#f.St, (70 ADDRESS eT V� � •'F� c LIC! '~ C� PHONE 22 `!tp SUBCONTRACTOR ADDRESS LICA' PHONE TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPIURIADDITION 14 DEATRUC110N ❑ ONO SFPrIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIS)I I HOW MANY Appliantion INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL yp OTHER 13 NUMBER OF LIVING UNITS: NUMBER OF BEDROOM: NUMBER OF EMPLOYEES;- - CHARACTER OF SOIL TO A DEPTH Of 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASE TRAP ❑TYPE/MFG I a 11 CAPACITY NO,COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION T'ROPERTY LINE ' LIFT STATION SIZE NEOF P_ h ` AND OIL SEPARATOR LEACHING LINE01 NO.A LENGTH OF IJS- 0 NCE TO NEAREST WELL/6 FOUNDATIONZ� PROPERTY LINE �L R 4 FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE_ I SEEPAGE PITS '1 DEmm E SIZ ��NUMBER 2 p DIRTANCE TO NEAREST:WELL O FOUNDATION J l? • PROPERTY LINE SUMPS, ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REOULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT'S BIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT iNTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIF RNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW, SIGNED f TITLE: C-C:1 J_�'i VILAL C)� DATE: ` n 31-1i6 PLOT RAN{DRAW TO SCALE)SCALE •to 1. NAMES OF STREETS OR ROAD$NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION 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 OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ..'.. .. t .. : .... � . . �` K I .......... o- ll IKr ...... - . .., . .. a ................... ..... . ....... ............. ................iw ... .. ,� . ,