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APPLICATION FOR UaLIIO WASTE PERMIT SAw•JOAOUIN COUNTY PUBLIC HEALTH S�JICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmplots in Triplints) APRICATON IB HEREBY MAGE TO THE BAN"AWN COUNEY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN ' "AWN G N 18 H DEVELOPMENT TNIF•CHAPTER 8'1110.3 AND THE RTANDAPDB OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. LOT SIZE C 1/1 S JOBADORIGGORAPN# <S/Yl/ I //.. L ..Ms1• MONE(6a-e O EEESNAME j7,71 C /1%cF• :n(ADD11E99 �/-/�Iy Gr.�"• r r f-•N COMPACTOR '_• .r_ LU11 '. ADDRESS �O PHONE LIG PONE ADDRESS BUB CONTRACTOR T-T TYPE OF SEPTIC WORK: NEW IN NSTALLATION y- REpAIR/ADdiIOM 11 DESTRUCTION PT ❑ PFAL iFSTI.)I I IOW MANY IVO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) APPIIo•Bon l INOTAUATION WILL SERVE: RESIDENCE 13MCOMMERCIAL❑ OTHER ❑ NUMBER Of LMNG UMTS:_ NUMBER OF BEDROOMS: MUM891 OF 6AROYEFS: CHMACTd OF 6011 TO A OEM"O.F.].FEET'- %�••�/ RT/SUMP SOIL LHAMCTEfl: WATER TABLE DEPTH SIMIC TANWORIJUE TMP EJ TVPE/MFO�-C - NO.COMPARTMENTS �- PKD TREATMENT RANT 11 DISTANCE TO NEAREST: WELL FOUNDATON POPERTY`UW LIFT STATION 0 SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM( J LFACNNO UNE I3-NO,S LENGTH OF LINES 1 ) he d r _DISTANCE TO NEAREST:WELL /FY'' FOUNDATION 1-? PROPERLY UNE 399 FILTER BED ❑WROTH LENGTH DEPTH DISTANCE TO REAM"!WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WFLLFOUNDATION PROPERTY UNE SUMPS ❑MOTH LENOTH DEPTH DISTANCE TO NEANEBT:WELL FOUNDATION FRROPEBTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL SE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE SAN IGACUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOM FORWHICH THIS PEIWTT IB ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME MWECTTO WORKMAN'S COMPENSATION IALVS OF CA MMA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 GNALL EMPLOY PERSONS SUBJECT TO WOMMAN'B COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED MOPECTONS. COMPLETE DRAWING BELOW. q /}wT� 11 C-0 A ti L•L DATE' L SIGNED% I/ ��/ � y TITLE � rc /IYI ROT RAN DRAW TO 6CMP SCALE_ -to / 1. NAMES OF STREETS OR ROARS NEAREST TO OR BOUNDING THE PROPERTY, *. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM R PROPOSED r 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE OISPOBAL SYSTEMS. 1 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS•DRIVEWAYS,AND WALKS. THE PRE I,'OR ADJOINING PROPERTY. dGkv ` $-e/ FOR DEPARTMENT USE ONLY _ / 1 APPLICATION ACCEPTED BV DATE: TANK,RT OR SUMP INSPECTION GV DATE/v l/J INSPECTION BY WAT •l� Ire ADDITIONAL COMMENTS: ACCOUIMNO ONLY: AID/ FAC* PE CODE FEE INFO AMOUNT RE W 1TED /CASH RELFN M BY DATE BR/RTMIT NUMam INVOICE* Pub.Health SON.-Enviro. 174(3/96)