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APPLICATION FOR LIOUIO WASTE PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ML" P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 962010388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmpIEm in TFipliaTE) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPME77'- N7T TTITLE,CHAPTERS-1 110.3 AND THE ST DAR OF SAN OAOUIN COUNTY PUBLIC HEALTH SERVICES,YNVIggq MENTAL HEALTH DIVISION. (^�y A,� JOB ADDRESSAORAPN+ / /' 1'7-L �� —�� I V 1C/ffV �� /T RS/1/�1 LOTSIZPJ/'-(��/ QF`t OWNER'S NAME r r V` ADDRE88 7 3? 3 :.�k) Y f'? 1 /" l _PHONE CONTRACTOR p ADDRESS UC+ RHONE SUBCONTRACTOR ADDRESS UCO PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPMRJADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM KRAITED IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.1 PERC TEST(.1 I 1 HOW MANY APNleecoe+ INSTALLATION MU SERVE: RESIDENCE❑ COMMERCIAL)( OTHER 13 NU MEM OF LIVING UMTS:_ NIAEEOM GF SEOMOMi: NUNSIM OF EMPLOYEEII:�3 CHARACTER OF SOIL TO A DEPTH OIFI�3I FEET: PIT/SUMP BOIL CHARACTER: WAT R TABLE DEPTH SEPTIC TANKJORFILEE TRAP IDI TY UMK�L-e U G1 C1 - -—CAPACITY �6 e3 4 NO,COMPARTMENTS 2 MG TKEATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LFT STATION❑ SIZE TYPE OF PUMP_ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ('� LEACHING UNE [3 NO.B LENGTH OF UNES / DISTANCETO NEAREST:WELL / 'FOUNDATION /U PROPERTY UNE 190 -4 FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE r^ MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAKEST:WELLFOUNDATION PROPERTY UNE SEEPAGE FITS ❑DEPTH SRENUMBER DISTANCE TO NEAREST:WELL_.rn FOUNDATION RmPERTY UNE SUM" ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION FROMM LINE .[[� DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE l I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES �C AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WDIK FORWHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR j SUB-CONTRACTI IGNATUAE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO N6ATION WS OA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPEC ONS. COMPLETE OMWIND BELOW. T/ �til7i�3 1 SIGNED% TITLE: DATE: ROT RAN IDRAW TO SCALE(SCALE -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NOUN DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 3 G fi l� f) IrMENi NIAY 2 8 1996 :"j5LIC HEAL �i SER'VIUE; NVI1`30MMENTAL HEALTH DIV13. APPLICATION ACCEPTED BV ! 1.l�C�Ki.t�_ FOR DEPARTMENT USE ONLY DATE: -y ! J /' I AREA: / SUMP INSPECTION SB � H � DATE 611 FINAL INSPECTION BY _ DATE rI.3VI2VCMMENTS: Q (.tI HY�L[�,t /i tel.✓rytw �Y'�f i� ��CiK L.r, c _ C.._ —�C .c. 'dZ '✓ ACCOUNTING ONLY: AIOI FAC+ PE CODE F AMOUNT REMITTED CNECKY A6X KECDVED BY DATE M I PERMIT NUMBER INVOICES Lt z i L �/at,�.i '7—',fS+.✓ �p�u- ��-/�—�2dt<i� � 661v1�v✓dL,rrn 3aca'7-�Irv� P� �