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4PPLICATION FOR UOUIO WASTE PERMIT SAh—JAOUIN COUNTY PUBLIC HEALTH SE.-,ICES (U`a ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TrIpIluls) APPLICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WNH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1/11110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY MOM HEALTH`SERRVICES,ENVIRONMENTAL.HEALTH DIVISION. JOB ADDRESBIOR AM' I � 1�Z/O f�� `�'�Z�t-(�CI� �V�.�t�J CNl' `�ISA�"1�� LOT SIZE OWNER'SNAME Jktj. af-Ml fL t-ji,--CI ADDRESS /1��14^41 PHONE ylL-Ig4r/- �i33a{ CONTRACTOR 1 TI ICJ I U IL< r ADDRESS RC1 UCl JE G SU LICF �� PHONE J/I-7 77� BUB CONTRACTOR ADORERS UCI PHONE TYPE OF BE IC WORK: NEW INSTALLATION REPAIRIADOITION ❑ DEfTRUCTION ❑ ]NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WTIHIN 100 FEET OF RUILDINO.I P C TU^.I I I HOW MANY S Gl9- 5 .4 INSTALLATION WILL 9131 RESIDENCE❑ COMMERCIAL fa'� OTHER ❑ NUPW ER OF"NO UMTS:_ NUMBER OF BEDROOM,: NUMBER OF SMKOYEFI: aa CHARACTER OF SOIL TOA DEPT,OFT�-D/FEET:�k\G. PTfSUMP SOIL CHARACTER: �i G/1(J_ WATER TABLE DEPTH SEPTIC TANK/011FABE TRAP NGTYPEIMFG L Y cAPAcrTY I a-O O NO.COMPARTMENTS ff• PKU TMEATMETIT PUNT❑ DISTANCE TO NE)JEIT: WELL La �• FOUNDATIONS_ PROPERTY UNE UO— NFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM( Ut LEACHING NE 8! NO.B LENGTH OF LINES I — 46 DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER SIM ❑WIDTH LENGTH DEPTH OIBTANCE TO NEAREST:WELL FOUNDATION PNOPERTY UNE MOUNDFD ❑.,/WIDTH LENGTH DEPTH DISTANCE TO NEAlEBT:WELL FOUNDATION PROPERTY UNE_ SEEPAGE NTS 1G DEPTH _SIZE 3c rl NUMBER DISTANCE TO NFAREBT:WELL FOUNDATION 31- PROPERTY UNE 3� SUM" ❑WIOTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPD,AL PONDS ❑WOTH UNOTH 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 BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 SOWED,I WALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOFKMAN'B COMPENSATION"WOOF CALFORMA.- CONTRACTOR'S HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES T14E FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PIRMTT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS GF CALIFOMIIAA.- T/HE.APPLICANT MUR CALL N HOUR(IN ADVANCE FOR ALL REGARM INSPECTIONS. COMPLETE DRAWING OMO/ \ SIGNED X I TITLE: G-p n'�nG L'FO ^ DATE: PLOT PLAN(DRAW TO SCALE)SCALE_ -tO (\ 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. ,. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED \\\l• 1. OUTLINE OF THE PROPERTY,WTTH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTETAS. 3. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. B. LOCATION OF WELLS WITHIN RADmB OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DAIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY.