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APPLICATION FOR Lima,WASTE PERMIT SAN JOAQI .OUNTY PUBLIC HEALTH SERVICES ENV—' MENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468.3420 L NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED ICBRnplits In TFiprMBEBI APPLICATION IS HERERY MADE TO THE SAN JOAQUIN COUftY FOR A PERMIT TO CONSTRUCt ANOIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE I f COMPLIANCE WITH DAN i JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. F h 1 r JOB AOORE68fOR 11.1 _� � 7!{� i:'.;iYc' � I� ___ _—� OW ., l L�.`" f LOT SIZE NAME fF.!Y-r% r�1lLG:� _ADDRESS '.-7 PHONE i f CONTRACTOR !'/; �-:=!/'Z!'tel � ADDRESS ...!Or f YY ^134i®iC�fLF7'LL1Ci RwNE •� ! `J . k sue CONTRACTOR ADDRESS UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION DESTRUCTION❑ � IND SEPTIC SYSTEM pT11MfrtEO IF N16UC SEWER Is AVAILABLE WITHIN 200 FEET OF BVILDIHO.1 FWG TESTI-1 1 1 NOW MANY APPEminn i INSTALLATION WILL SEINE: RESIDENCE COMMERCIAL L7 OTHER❑ NUMBER OF WING UITII:I_-NUMS&1 OF tImROOMi: NUMBER OF BAPLOYEFS: - CHARACTER OF SOrL TO A DEPTH OF z PEST: Ak)z5 C- PITISUMP ROIL CHARACTER: WATER TABLE DEPTH I SEPTIC TANIVOREASF TRAP ❑TYPE/MFO �-F'L__-_ ,--_-CAPACITY NO.COMPM[TMENT6 - _ _ _ PKO TREATMENT PLANT L1 DISTANCE TO NEAREST: WELL FOUNDATION PROPFRTY UNE UFT SYATtON❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED BYSTFMI LEACHNO LINE FII NO.A LENGTH OF LINES I' `• DISTANCE TO NEAREST:WELL -�J d11NOATIONT710PERTY UNE 6 I LJ J V POSTER ago WIDTH LENGTH OFFTH DISTANCE TO NEAREST:WELLFOVNDATtON PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL'`��FOUHOATION PROPERTY LINE ' SEEPAGE RTD ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL J FOUNDATION PROPERTY UNE /y —T StSAPi .�1 WIOtH?� -'-LENG7N�_OEFTH DISTANCE TO NEAREST:WELL}_FOUNOATgH PROPERTY LNE ! . J DISPOSAL PONOS 0 WIDTH LENGTH DEPTH DISTANCE 70 NEARESTI WELL FOUNDATION PROPERTY LINE C 1 HERERY CERTLfY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOACUIN COUNTY.HOME OWNERGRLICENSEO AGENT'S SIGNATURE CUITIFIESTHE FOLLOIMNO:'ICFRTIFYTHAT INTHEPFRPORMANCE OF THE WPfi[FORVV1nCN THIS PERMIT to ISSUED.I SHALL NOT EMPLOY ANY PERSON RI SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALWORMA.' CONTRA! CTPR•e NIRINa OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORC FOR WHICH THIS PERMIT III ISBUED.I SHAEMPLOY PERSONS SUBJECT TO r . WOIKAIAN'B COAKPENDATM/jN/LAWS OF CALIFORNIA.' THE`APPLICANT MUST CALL x HOURS tN ADVANCE Rai ALL RT9BLHLED INSPFCT1oNe. COMPLETE DRAWING BELOW. S[GNEGX_fCy/' L' TITLE: _ DATE: f I PLOT PIAN[DRAW TO SCALEI SCALE F 1.NILMEB OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED x.OUHE OUTLINE OF TPROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6.LOCATION OF WELLS WITHIN MOMS OP ONE HUNDRED FIFTY FT.OR INCLUDING COVETED AREAB SUCH AS PATIOS.DRIVEWAYS AND WALKS. THE PROPERTY011 ADJOHNING PROPERTY, _.. - .. - .. ..... ..... ... y 1.7 . . ..... .. , e. a r:......, ;.. . ... . .. 'fry . ............ .... ............ ................ ..... MN JOAC Uf N C!IUP!I Y . F' FOR DEPARTMENT USE ONLY 7 J S- ` RIA. q / DATE: � A �—� APPLICATI7AICCEPTED BY;, - - -'— TANK.PIT BY DATE I I FINAL INSPECTION BYk ADDITIONA ACOOUIITINO ONLY: ND! FACS PEC I� FE`NFO AMOUNT�QLTEED HEC (CASH RECEIVED BY DATE ' an I P601G7 BFR INVOICE i� y I S 4 Pub,Health Sem.-Envlro.174{3196) a