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OLSD 7s� APPLICATION FOR LIOUIO WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTTT--SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IOampleta In Tripliealq APPLICATION IB HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER/9-11110t.3'AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADORESeroR AM, 6`9.FOS`k/. FR--yy�)� Rb LAT 4WW P IA Jcr�ry !—/�r I�ROS' LOT SIZE I AC OWNER'S NAME /`I CHA P-D SlA460 ADDRESS 1I77P•O . BiOX 2!!7�E''GSGA L0� 9r 7.-B PHONE G/y CONTRACTOR VAI- Ej ACS 2F_S�A4wo ADDRESS ( . O- ROK '3744 I uga-a x UCJ RHONE 57.1- 79/ SUB CONTRACTOR ADDRESS LACI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAMAUNTION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEAC TESTI.)1 I HOW MANY 7 AppNwtlen J /`\� INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ l`.. NUMBER OF LIVING UMTS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: _^� CHARACTER OF SOIL TO A DEPTH OF 3 FEET: RTISUMP SOIL CHARACTER: WATER TABLE DEPTH ( BEPTIC TANK/OREASE TRAP ❑TVFE/MFO CAPACITY NO.COMPARTMENTS PKU TREATMENT RANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PIMP SAND OIL SEPARATOR IENCLOSEO SVSTEMI LEACHING LINE ❑ NO.B LENGTH OF UNE6 DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BUMPS 11 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE - I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE POLLOWINO:-I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN-9 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOWMAN'8 CONK ION LAWS OF NIA.- THE APPLICANT MUST CALL 26 HODU IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPETE DRAWING BELOW, SIGNED X �-,— A TITLE: DATE , PLOT P/L} (DRAW TO 6CALE1 SCALE_ 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE MQPERIY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. - 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RAIRIS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXS, THE PROPERTY OR ADJOINING PROPERTY. (LoTF 2D 4 0 F/ZEw� Ros�D �• L JMr yy � PRPYoS�D q SU ILMI Iw1.(q: Ilk P, a� Sim �AEC P�AYmENTRECEIV 3 1997' tiAN J6AL]LJIN. C) NJ PU9UC HEAi,wLT4 iERVV CES �,}V\�I\�\ Fw(� 4 }{OEPAP TMEHT USE ONLY �_1I APPLICATION ACCEPTED B , � \ \ \ M,\11'17'Y `FORPo"FF DATE: �"� AREA: TANK.RPET OR SUMP INSV DATE I I FINAL INSPECTION BV DATE 1.21 ` ADDITIONAL COMMENTS:_ C ACCOUNTING ONLY: AID' FAC, PE CODE FEE AMOUNT PEMII E )IEC ICASH RECEIVED BY DATE SX PERMIT NMI INVOICE) D } 3-73' I Pub. ^ Health Serv. Envtro.176(3/96) 'Jl