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- s PLICATION FOR LIOUIO WASTE PERMIT .r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION pt(( 304 EAST WEBER AVENUE, STOCKTON, CA 95202 V/ (209) 468-3420 10N"RETONOAOI[_LEA IT EXPIRES I YEAR FROM URTE 198UED ICBmplotO In TTlplkBtq APPLICATION IB HEREBY MADE TO 114E BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDrOR INBTAI L THE WOR(DESCRIBED. THIS APAJCATION IB MADE IN COMPEANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER/91-1/11100.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PEBUC HEALTH GEEFMCEB.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMIR AM'' / <ae � / !'1 L/F��+�L�/T P-rl • /� I 'C" Yrs //A� LOT SIZE OWNER'8 NAME TF�LYFC ADORES. P0-B/jE��K gj9�/0 wf S' L��V150�`��11A (MON y/�)� 2 , CONTRACTOR VA14-P4 A6 1�! EEAW / AODRE66�•V , OigX! ! - 4 P K�VL UICF R10NE " A4/ SUB COER"CTOn ADDRESS UC/ MONT TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPNR/ADDITION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMITTED IF PVSUC SEWER IS AVAILABLE WITHIN 200 FEET OF SURJMNO.1 PEILC ESSEN)I//I HOW MANY bWla.Son• E�� INSTALLATION WILL SERVE RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF"NO UMTS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES T""✓�.E..\`� CHARACTER OF SOIL TO A DEPTH OF 3 FEET: RT/BUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANIUCREASE TRAP ❑TYPE/MFD CAPACITY NO.COMPARTMENTS 1 PXU TREATMENT PLANT❑ DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PIMP SAND OIL SEPARATOR(ENCLOSED SVBTEMI LEACHING UNE ❑ NO.B LENGTH OF LINES DISTANCE TO NEARESh WELL FOUNDATION PROPERTY UNE FILTER BID ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑MOTH UNGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PEVFEHTV UNE SEEPAGE PTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PERGPiRTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PIIOPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'SSIONATURE CERTIFIESTHE FOLLOWING:-ICEITUFVTHAT INTHEPERFORMANCE OF THEWORK FORW N THIS PERMIT 18 ISSUED,I SHALL HOT EMPLOY ANY PERSON M BEACH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONEIRCTOR'9 HIRING OR SUB LOM ACTINO m URE CERTIFIE N FOLLOWINO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP A ION lAWB 0 ALIF RNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. elONEO% TEE /�/�C DATE: ROT N(DRAW TO SCALE)SCALE 11Ala L /Y%jam 1. NAME$OF STREETS OR ROADS NEAREST TO OR BOUNDIN THE P10PERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PHOIOSED 2, OUEUNE OF THE PIOPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DHIIVSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PRO(OSED STRUCTURES, 6. LOCATION Of WELLS WTTH)N BADGES OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAB SUCH AS PATIOS.DRIVEWAY&AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. N ,A // wy GEF - - ,¢JBIMP LOLATIOAI MAaaa irA N w _ . PAYMEN-1 RECEIVED SEP 14IM SAN.JOAOUIN CJUN;Y PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �— r`— FOR DEPARTMENT USE ONLY LIZ AMICATION ACCEPTED By_�C�V�'EA'a I'CJ�I L�^'L y`- DATE: I AREA S TANK,PT OR SUMP INSMCTIO14 BY n DATE / / FINAL INSMCTION BV DATE 7 ADDITIONAL COMMENTS: I, Z. WL. ) -e,7 y 1" /In r ACCOUNDNO ONLY: AID' FACE R CODE FfE INFO NMOUNT REMIITEO CIIECIV ASH RECENEO BY DATE 6Rr P60.11T NUMBER INVGICEI Pub.Health Sery.�Enviro. 174(3/96)