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APPLICATION FOR UOUIO WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFURDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompltte In Trpliutal APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE MTN SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH/SERVICEES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR/AAPNNFI /i{ J G z I N/ —9 ,,ter/ 1 wE�- ,I y ) CRV !/—LJ AJ 1LOT SIZE OWNER'S NAME O`L�VY" Ey 15iFLF— Ci1Lt�E"/ ADDRESS P-- L( • b3 301X 16/16) I—c;D!I j,-;-24o RHONE !/4-/f-y 91110) CONTRACTOR VALLG_Y1V-f IZFI �" tW ADDRESS P,49, Oak 2714 URZ,6K UC, P10NE U' I"/e'/ SUB CONTRACTOR ADDRESS UCA PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR1AD04T10N ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEV VER IS AVAILABLE WNHIN 200 FEET OF BUILDINO.1 PDIC TEDT"I I 1 HOW MANY Z APgln don J INSTALLATION WILL BEAVE RESIDENCE❑ COMMEMIAL ❑ OTHER ❑ NUMBER OF LUNO UMTS:_ NUMBER OF BEDROOMS NUMBER OF EMMOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PT/SUMP SOIL CHARACTER: WATER TABLE OEPTH SEPTIC TANK/OLEASE TRAP ❑TYPE MM CAPACNY NO.COMPARTMENTS WO TREATMENT PANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WDTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PbFERTY LINE 1 HERESY CERTIFY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER ORUCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE MW FOR WMICH THIS PERMIT 18 ISSUED,1 SMALL HOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO MMMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB CONTRACTING SIGNATURE CERTIFIESTIJE FOLLOMNG: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,1 SHALL HVIMOY PERSONS SUBJECT TO WORKMAN'S COZ71ON LAWMOFIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPETE DI WNO B ELOW . I� 00SIGNED X ✓ �" LSF " TIT /LE: DATE: / L/ / !Fid' 00 PLOT N BYRAW TO SCALE(SCALE_�I/ - G' 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUND( THE PROPERTY. /v U e— -46 A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYIETEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROMSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS, THE PROPERTY OR ADJOINING @ P�RyOPIEEpRBT,Y..Lp�ry, 1'"BP�+n/SpilCM E-N �10 DEC 1 1998 cz I, 1 u SAN JOAQUIN COUNT) ENVIRONMENTAL HEALTH DtViSl(" .� r- molvIl 1N 111 fL :. ARTMENT USE ONLY _ E: AREA: APPLICATION ACCEPTED BV41 S^' OAT/. CC `l Ill 2 TANK,PR iJ OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY I' DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID' FACA PE COOL FEE INFO AMOUNT SEMI I TED CI CE1 W/CASH RECDVFD NY DATE SR I PERMIT NUMBER INVOICE/ Pub.Health SON.-Enviro.174(3/96)