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3z APPLICATION FOR Liam WASTE PERMIT S1JOAQUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION ; '} 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)46&3420 e) ,. NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED �t�"a- j (Campfata In TripRRata1 /� APPLICATION IS HEREBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IH MADE IN COPIy.IANCFiVNTH BAN II' JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1/110.3 AND THE AN AIRDS OF BAN JOAtlU1N rCOUNTYPU�8,L�1C HEALTH SERVICES,ENVIRONMENTAL HEALTH WV18K1N•�1 4 JOB ADDRESS/OR APNI' / - ` L C• { CITY L b L p LOT SIZE 07 OWNER'S NAME ADDRESS C/ CONTRACTOR ADORES S L.ICI PHONE �.. ADDRESS LICE _PHONE , BUB CONTRACTOR ,j f' DESTRUCTION❑ I{ k TYPE OF SEPTIC WORK: NEW INSTALLATION RLIAIRIADDITION 11 � TWO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AV LABLE WITHIN 200 FEET OF BUILDING.) PERO TESTISI 1 1 HOW MANY i Appansdon 1 INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL 13OTHER 13 , NUMBER OF LIVING UNITS: NUMBER OF SEDROOMS: NUMBER OF EMPLOYEES: � CHARACTER OF SOIL TO A DEPTH OF 7 FEET: PITIGUMP SOIL CHARACTER- WATER TABLE DEPTH CAPACITY NO.COMPA iTMENTS SEPTIC TANKMIREASE TRAP TYPEfiAFG PROPERTY UNE PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: - WELL FOUNDATION = TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LIFT STATION❑ SIZE LEACHING LINE ❑ NO.a LENGTH OF LINES - DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER Stb [3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE FITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SmP6 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 'I IENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONOS (3 WIDTH I I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES NT'881GMATURECERTIFIESTHEFOLLOWING:'ICERTIFYTHATINTHEPERFORMANCEOFTHEWORLFORWHICH /1NDREOULATIONSOFTHESANJOAWINCOUNTY.HOMEOVYNERORI]CENBEOAOE THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOHLMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S SUBJECT DR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO E W SUB-CONTRACTING COMPENSATION LAWS OF CALIFORNIA-' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOLXRED INSPECTIONS. COMPLETE DRAWING BELOW- if BIOMED X TITLE: ( DATE: 1 PLOT PLAN IDRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. I 3. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, a. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON THE PROPERTY OR ADJOINING PROPERTY, INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS' - - - - f ............. . .......-.. L �rwl ...... ....--- .. �.7C--' Cl_ 1 !!.. � r I : l I. 3 pA 1 I ENION .. O :.=YYY+ I ' . .. I ............:. ....:..... CHEAL �!y ON 4 FOR DEPARTMENT USE ONLY n PE �kz _tom-.:APPLICATION '--�bATE: ' 1 i Y '/ - E L I. TANK.PIT DR SUMP tNBPECTION BDATE I FINAL INSPECTION B Y ADDITIONAL COMMENTS:_ O ACCOUNTING ONLY: R FACS PE CODE FEE INFO AMOUNT")TED CHECK) ASH RECEIVED BY PATE SR I PERMIT NUMBER INVOICE f fiLa a (p 63 < r Pub.Health Serv.-EnvirO.174(3196) $ je / sy60