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APPLICATION FOR LIOUIO WASTE PERMIT PAYMEN 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 OCT 2 3 2000 (209) 468-3420 SAN JOAQUIN COUNTS NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM 0117E ISSUED �1,��P�U/�B�LII�C��HEEpALT1JH�SS�ER1{VI(C�'Ev1S5I�� (CBmP1ttS In TAPH"ttl AFMICA1RNyB 11[RAYIF,CADE19 W4%1 1 JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. THIS APPlKAT10N IB MADE IN COMRIANCE WITH BAN "AWIN COUNTY DEVELOPMENT TIME,CHAPTER 9-1110.3 ANO T 6TANDARDB OF BAN JOAQUIN COUNTY NBUC NEAVHy VIC ENVIRONMENTAL HEALTH DINBNJN. '7 J I r r r S LOT 812E .J %TC. JOB ADDRE68NCm'R AM' G I� �c- J OWNER'S NAME ADDRF.59 JY D 1 I V " ,r vuL�L.Lti� FMONE 7J T Y L' rY� / Q .� CONTRACTOR_ �.� lT l'l JN S'F ADDRESS qu �("1 -J � �Q Inc. 11576Y/ SUB CONTMCTOR ADDRESS UCI PHDNF TYPE OF SEPTIC WORK: NEW INSTALLATION MPAIRADDITION ❑ DFITRUCTION ❑ m INO SEPTIC SYSTEM PERMITTED IF RIBUC SEWER I6 AVAILABLE WRMIN 200 FEET OF BUILDING,) p91C WI 1 NOW MANY - App4stlon I INCULLATION Will BRAE: RESIDENCEI% COMMERCIAL ❑ OTHER ❑ NUMBER OF LAVING UMTS:—j— NUMSER OF BEDROOMS'. MI.MB[R OF BA0.0YEFl: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: RT/BUMP 601 CHARACTER: WATER TABLE DEPTH nn I p NO.COMPARTMENTS n SEPTIC TANIVUREASE TRAP ❑TVPEMF0 UCL•i C+' CAPACITY—I PRO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OFNMP y SAND OIL SEPARATOR IENOLOSEU SYSTEM) USACNNO UNE ❑ NO.\LENGTH OF LINES A 1- 0 / DISTANCE TO NEAREST:WELL /CL.,IL.•I- FOUNDATIONPROPERTY UNE �S FILTER BFI ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOLMDED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE L .T &MADE RTS ❑DEVTH _SIZE 41 y NUMBER_DISTANCE TO NEARIEBT:WELL �sa•tFOUNDATION /Q/ FigPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION FPORRTY UNE DISPOSAL PONDS ❑VROTH LENGTH DEPFN DISTANCE TO NEAREST!WELL FOUNDATION PROPERTY LINE - I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS A (CATION AND THAT THE M3HK LMLL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR UCENSED AGEM'S SIGNATURE CERTIFIES THE FOLLOWING!'I CERTIFY THAT IN THE PERFOMIANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUWFCT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB.CONTR%CTINO SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE M WORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I BNAM EMPLOY PERSONS SUBJECT TO WORKMAN'S COM NSATION PAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOLMS IN ADVANCE FOR ALL REUUPPPL RED INSECTIONS. COMPLETE DMVANG BELOW. SIGNED x H�•�"'-'/ � TITLE: en `�V-A d-4 O r DATE:1-0 -`/6 nC7 POT MAN DRAW TO SCALE)SCALE--'to 1. NAMES OF STREETS OR ROAD8 NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL"STEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,VATH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DImUeAl SYSTEMS. 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WFLLB WRMN RADIUS OF ONE HUNDRED FIFTY ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIXe. THE PROPERTY OR ADJOINING PgPERfY. i 2ZZ� B6, S tF ,00 , HID � wed v J TIP.9�4+ EN-vWT USE ONLY _ L� 1 7Z� U' V V v- DATE' AMA UX APPLICATION ACCEPTED By `�T/L� 1 TANK,PT OR BUMP INSPECTION BY FINAL DATEWSPECTION BY DATE VI ADDITIONAL COMMENTS: ACCOUMTMO ONLY: MOP FAG DIE CODE EEE INFO AMOUNT REM) TED CIIEC ASH RECEIVED BY GATE SR/pRWNT HUMBRI INVOICE I Pub.Heetth Sew -Envirn.174(3/96) �l