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APPLICATION FOR U(IU10 WASTE PERMIT 006) /9:Z,2,_ SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComPlBE6 In Triplieabl APRICATMN IS HEREBY MADE TO THE BAN JOAOUIN COUNTY FORA PERMIT TO CONSTRUCT ANDMR INSTALL THE WORK DESCRIBED. THIS APPLICATION NS MADE IN COMPLIANCE WITH BAN TY JOAQUIN COVNDEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH ENVISION. JOB ADDRESSMA AM# 5 'S 9'/l),� /3 /' y�TL r�N� cm ZA/yiA �, LOT WZE_ OWNER'S NAME E/ L pt ADDRESS J� w PHONE CONTRACTOR rC/r.�. f�/��/� ADDRESS Aslo BUS CONTRACTOR ADDRESS lKf PIIGNE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ gEPAWAOdT10N ImaTINCTION❑ IND SEPTIC SYSTEM PEHMTTTEDAF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILpN0.1 PEF1C TESTI.)I 1 HOW MANY AppNOFtlon I INSTALLATION WILL SERVE: RESIDENCE Lo�y COMMERCIAL ❑ OTHER ❑ NUM6ER OF"NO UNITS;_L NUMBER OF BEDROOMS: ? NUMBER OF EMPLOYEES: CHARACTER OF SOILTOA DEPTH OF 3 FEET: C-- PITIBUMP SOS CHARACTER: WATER TABLE DEPTH 6FPTIC TANK/OREAEE TMP ❑TYPIMFG Q4 L CARAcm (I// NO.COMPARTMENTS MO TREATMENT RANT❑ DISTANCE TO NEAREST: WELLV tF FOUNOATN)Ni"3c,Ff PgOPERry LINE LIFT STATEN 11 SIZE TYPE OF PUMP SAND OIL SEPARATOR ENCLOSED SYSTEM) LEACHING LINE ❑ NO,B LENGTH OF LINES r DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER SED LR MOTH $r, LENGTH /A-J FOFPfH ,1 DISTANCE TO NEAREST:WELLQ9tff PoUNDATN1N i'�PWPERTY LINE MOUNDED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATgN PgPERTY LINE SEEPAGE P76 ❑DEPTH SIZE-NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIDTH LLNOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION POMITTY UNE DIS"SAL"NOS ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE MRK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER ORMENBED AGENT'S SIGNATURE CERTNIES THE FOLLOWINO:'ICEMIFYTHAT INTHE PER FMANCE OF THE WORK FORNMICH TMI6 RRMR IB ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO W MMAN'S COMPENSATION LAWS OF CA MMIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTINO MONATUBE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMROY PERSONS SUBJECT TO WORKMAN'S COMPENSATK)N LAWS OF CALMMIA.- THE APPLICANT MUST CALL 24 MUS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE ORAMINO BELOW, sy G jam/ SIGNED X�� TITLE:� DATE' ROT PAN OMW TO SCALE)SCALE_ •to 1. NAMES OF STREETS OR MADS NEAREST TO OR BOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE MSPOSA SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTETA6. 3. DIMENWONED OWIJNES AND LOCATION OF ALL EXISTIMO AND PRO"SED STRUCTURES, 6. LOCATION OF WELLS W HUN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. i. c f fo .. R �3 FI I � PAYMENT I � JUL 3:0199$ MPUB�NJOAQUTNCQUNTY .. _.. ENVIRONMENT Tj!gLRVICES N p. AL 4 RA FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY i1 DATE AREA:_ TAA(,PIT ORSU8SUMP /7IIpNNN/SSO�KCTIO14,By / i�� /+� DATE I I' n FINAL IN6RCTION BY DATE I ADDITIONAL COMMENTS /lY(- FJp 11J rr,Al lJ/ WEN. I t NLY: AID. FACT FEE INFO AMOUNT REMIITED CNFL CAS- DATE OL/PERMIT NUMBER INVOICE• *411$ Lb -7l-t>1g8' Pub.Health Sow.-Enviro, 174(3/96)