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•• 7 _ APPLICATION FOR 00010 WASTE PERMIT SAN JOAOUIN COUNTY PUBLIC NFAIIII SERVICES ENVIRONMENTAL HEALTH DIVISION P-O. BOX W, ,304 EAST WEBER AVENUE:, SPOCKTON, CA 9S201-388 (209) 488 342.0 NON REFUNDABLE PERMIT_ XPIHES 1_YEAR_FROM-DATE ISSUED (Comp6l6 in TripliclF6) API•LICAIION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DERCRIBED. THIS AF'f'LICATION IB MADE IN COMPLIANCE WITH SAN JOAGUIN COUNTY DEVELOPMENT TITLE,,'CHAPTER 9-1110.3 AND THE STANDARDS OF BAN.IOAOOIN COUNTY TR)BLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADORE 66lOf1 AAP�Nf�.00 I - 1_l �A V� 1 �(.�k -_._-• .(�' n�� CITY_ ��/I_,\}�,,l C�Iv c� _ lot 61ZE_ _ OWNER'S NAME-1L_1di—. /OUI)RF6S �2 �1 Is�- SA �C �91 Cr / COfJIfLACTOft_ K1r Eylf.,ldcr- AUDNESS_Z�' ��'#" _�__IICI �)��{� T'LiONE��g 1345 SUR CONI RACTUR AU(1R(E 66 t LIC/ T'110NE TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ --- •� �L IND SEPTIC SYSTEM PfHMIITED IF PUBLIC SEWER IS AVAILABLE WITHIN 20OFEEI Of BUILD1NR 1 PEEK TESI(.lj'1110W MANY y" _ IN6TAlLAT10N WILL SERVE: RESIDENCE❑ COMMEWAAL ❑ OTHER CI NUMBER OF LIVING UNI76:__-_- NUMBER OF BEDROOMS: NUMBER OF FMPIOYEFS:__ CHARAC TEN OF SOIL.TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: _WATER TABLE DEPIII SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY _ _ _--_NO.COMPAR1 PKU TREATMENT PLANT El DISTANCE TO L NEAREST: WEL _ FOUNUAI LUN PROI'EIRY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACHING UNE Cl NO.S LENGTH OF LINER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER SED ❑WIDTH LENGTH_ DEPTHDISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGI it DEPTH _DISTANCE TO NEAREST:WELL_ FOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTfI SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNI 6UMP6 ❑WIDTH_ LENGTH DEPTH _DISTANCE FO NEAREST;WELL FOUNDATION PfTOPERTY UNE DISPOSAL PONDS ❑WIDTH IENGTII_ _DEPTH, DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ` I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TILE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQLRN COUNTY ORDINANCES AND STATE LAWS,AND RULER AND REGULATIONS OF THE SAN JUAGUIN COUNTY.HOME OWNER OR l ICENBED AGENT'S SIGNATURE CERT IIAES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK fOR WHICII 11116 PERMIT 1618SUED,I SHAII, NOT EMPLOY ANY PERSON IN SUCH A MANNER AS 10 BECOME SUBJECT TO WOWMAN'S COMPENSATION LAWS Of CAUFORWIA.' CONTRACTOR'S HIRING Oft SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO / WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' 711E APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED XLav-t�1 } Q,(,(�' IL TITIE�- __._— -1 _ V ATE:—_—L- F'L I�DItAW TO SC AI EI SCAT E----- (•I_a� 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE W(OIIHTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIREC[ION. EXPANSION OF 6EWA(lE DISPOSAL SYSTEMS. 7 DIMENSIONED OUIIINES AND LOCATION OF AIL EXISTING AND I110POGf R1 STRUCTURES. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOMD FIFTY FT.ON INCLUDING-COVERED AREAS SUCH AS PAT 106,DRIVEWAYS,AND WALKS. THE PI701'Ef1TY OR ADJOINING PROPERTY. J OAK STREET I rn m 7 C7 m .. 11 ,r/.N.,-- /IAO PoaE9 �i TE N(.0 ' MAY: 12 1998 SAN JOA%11TH Ci}'1^;1Y YUL3Lai'ii?:•�>,!i N 911hPJIt:cS I�NVIHC)N1vi1;N1'A(HEALTH I�1yISl(]P1 CFOR DEPARTMENT USE ONLY I AfPLICAfIUN ACCEPTED BY_ � _ � _ CAT E;— AREA; (4 RANK,PIT OR SUMP INSPECTION BV DATE_ / / FINAL INSPECTION BY �_. (7: Ccs-Q DATE 'J' / ! /c(0 ADDITIONAL COMMENTS: (' "i- )^t ',•! .R(�F oS'4 30 ACCOUNTING ONLY: AIUf FAC# 5 CODE FEE INTO AMOUNI REMII IED HECKI 'ASH HECDVED BY DATE 8R r PERMIT NUMBER INVOICE f