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-ILICATION FOR LIOU10 WASTE PERMIT SAN Jbr,DUIN COUNTY PUBLIC HEALTH SER'%--.• ;S ENVIRONMENTALESTOCKTONLTH 10 A 95202 ON 304 EAST WEBER AVENUE,U9) A.68.3420 25-3 0 NflN REFUtIpABLE PERMIT fxp1RES 1 YEAR FROM DATE ISSUED {Compl/tB in Tripl'NBt+! MADE TO THE SAN JOAOUIN COUNTY POR A PERMIT S10 TANDARDS SF 8 T ANDPOR NIC TALL THEWORK HEALTH 8DESCR1ERVICEB.IENVFo"MENTAL HEALTH DIVISLONANCE WITH SA ArViCAT1ON IS HERESY MA /d G LOT 017E — TV COUNTY DEVELOPMENTT T111TLE.CHAPTER 9-1110.3 AND THE STAN A Cm rl • / _ / S " 1 P410NE JOB ADDREBS/OR APNF V �r ADDRESS �� j.y�r�x� RHONE ! aarti �]—7 f OWNER'S NAME .0 �F-r lr ADDRESS LlC0 J�PHONFf� CONTRACTOR ADDRESS SUB CONTRACTOR DESTRUCTION ❑ TYPE OF SEPTIC WORK: NEW INSTALLATION EWEn1 ❑ REPAIRJADOITION © PERC 7EAT{+1[ 1 HOW MANY IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 260 FEET OF BUILDING. psilOn� COMMERCIAL ❑ OTHER❑ INSTALLATION WILL SFRVE: RESIOENCE V NUMBER OF EFAPLOYEEB: NUMBER OF ILMROOMS' NUMBER OF LIVING UNITS: ABLE TIE RTISUMP 601L CHARACTER: NO.COMPARTMENTS CHARACTER OF SOIL TO A DEPTH OF]FEET: CAPAC...— SEPTIC TANKIGAEASE TRAP ❑TypE/MFO FOUNOATIONPROPERTY UNE �� pKD TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL. AND P1L SEPARATOR IENGLOSED SYSTEMI ' LIFT STATION❑ SIZES TYPE OF PUMP J FOUNDATION__ PROPERTY UNEP NO.S LENOTH OF LINES DISTANCE TO NEAREST:WELLPROPERTY LINE LucIIING LANE ST:WELL FOUNDATION ❑WID7F{ LENGTH DEPTH DISTANCE TO NEAREST: �� FILTER BED FOUNDATION PROPERTY LINE, ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL MOUNDED FOUNDATION PROPERTY LINE SIZE NUMBER DISTANCE TO NEAREST:WELL SEFRAGE q7S ❑DEPTH FOUNDATIOk PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELT DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNOA710N PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDWANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'L CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH ION T1418 PERMIT 19 ISSUED,ICT TO WORKMAN"' SUR-CONTRACTING S{ONOR ATURE ALL CERT CERTIFIES TTHEPLOY FO LOWING:RSON'1CERTIFY SUCH A FTHATER AS TO IN THE PESECOME RFORMANC OF THE WORK FOR WHICH THIS PE rl)v188UE0,I BIiALLS OF 1EMPLOY PERSONS SUBJEA.- CONTRACTOWS CT TO WOSKMAN•S COMPENSATION LAWS OF CALIFORNIA.- THE APPUCANT MUST CALL 24 HOUFS IN ADVANCE FOR ALL SCOURED INSPECTIONS. COMPLETE DRAWING BELOW. +y RIONED X ""Ile ` TITLE: v k.1 r��' DATE: G ~c1 PLOT PULN IDRAW TO SCALE)SCALE_ 'I° 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RAWUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY ' o .. ' P 1 .. �— v �,.. ...... >... .. . >. . ...........:.. . .... ... rr� "M :..... . .. .... t[4�Jj ;..... ..... ............ V1€iti i f 111?�t JI`= fN J� PUBLIC H EN �NtvlFt�tl ..... ... w� �..� ......... .�.. .. DEPARTMENT USE ONLY APPLICATION ACCEPTED BY L ` J DATE: A; E �'l,!1• TANK,RT OR SUMP INSPECTION BV DATE 112144 FINAL INSPECTION BY DATE_.Q i2 1 oI ADDITIONAL COMMENTS: xhoefc 25 ACCOUNTING ONLY: MD FAC,r PE CORE FEE INTO AMOUNT RFMr1 TED CHEC CA6H RECEIVED BY DATE SR 1 PERMIT NUMBER INVOICE E o Pub.Health Serv,-Enviro. 174(3/96)