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APPLICATIO' 7 Liam WASTE PERMIT SAN JOAQUIN C. -.lY PUBLIC HEALTH SERVICES _ ENVIRONISSENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE, STOCKTON,CA 95201388 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CemplotE In TrolicatFl APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED, THIS APPLICATION 18 MADE IN COMPLIANCEIT WITH BAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER B-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 3 ADDRESS/OR APN/ 4"4- pCITY T;LlAj T-o LOT SIZE //'' Ac.<3E2T',�I.+T 7c!-�' tom— -' -F "i`I'NER'S NAME W i �.-✓1'O�/J!•- �p//.,A,,,,A( ADDRESS V RHONE /'7 4-—Z ICI ,(( I C CONTRACTOR(V(i I/O./4J:)/-"iZyy.tJ ("e- ADDRESS Z Z 1401. G '"u✓ c.�J, G,�Di,`-q LICI 5`1V/(J PHONE 3107 3 7J� 3 CONTRACTOR ADDRESS UCI RHONE PE OF SEPTIC WORK: NEW INSTALLATO REIN IRIADDITION ❑ DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.I P9RC TESTI.I 1 1 HOW MANY / .J ApolwSon e TALLATION WILL SERVE: RESIDENCE Cl COMMERCIAL❑ OTHER _AGER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMSER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF D FEET: PITI6UMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKJWEASE TRAP ❑TYPE/MFGCAPACITY NO.COMPARTMENTS I TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) ITACHSNG UNE ❑ NO.E LENGTH OF LINES D18TANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER$FO ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE LANDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE PAOF RTS ❑DEPTH 81ZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE -,.IPS ❑WIDTH LENGTH DEPTH/ DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE REBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULER )REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I C ERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH 3 PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'8 HIRING OR s!B CONTRACTING SIGNATURE CERTIFIES THE FOLLOWINO:'i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPS 6ATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IM ADVANCE FOR ALL REQUIRED INSPECTIONS. COMB-ITE DRAWING BELOW. r _ NED X ! /�(, /--.-�-�'�'^wl TITLE: L"Y'- '[, 1�-I G,i JEGI'L DATE: / ( `r' -� PLOT PLAN(DRAW TO SCALE(SCALE /.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON JCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. r_ PAYMENT - - JUL 1 sni<vc ouIN oouN'r, PUBLI$I LTM SERVICES ENVIRONMENTAL HEALTH DIVISION - r--. (h a FOR DEPARTMENT USE DNLY / (CATION ACCEPTED BY - •"'�/�'4Y(Y' �J '�"'l:. / I i DATE: AREA: !' K,RT OR SUMP INSPECTION BY ET, ] / DATE {�I / FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: \ n \/L^C '�-- I V U-'t,` -i �.��rZ-^'L �- CCOUNTING ONLY. AID/ FACT PE CODE FEE INFO AMOUNT REMITTED CIL—Ki/.ASH RECEIVED EY DAT[ SA I PERMIT NUMEW INVOICE r