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APPLICATION FOR UaIIIO WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTh-SERVICES D�^ggq ENVIRONMENTAL HEALTH DIVISION I . 304 EAST WEBER AVENUE, STOCKTON, CA 95202 �{-• (209) 468-3420 I NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICamplett In Tripliaatq APPLICATION 08 HEREBY MADE TO THE BAN JOAQUIN COUNTY MR A PERMIT TO CONSTRUCT MDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMMANCE WITH BAN JOAOUIN COUNTY DEVELOPMENT TE%E.CHAPTER B-111100.0 AND THE STANDARDS OF BAN JOAQUIN COUNTY FUSLIC HEALTH ' SERVICES.ENVIRONMENTAL NVIRONMENTAL HEALTH DIVISION.IVISION. JOB ADDRESSOR AM' / O CITY t5E ,L— LOT SIZE / S T OWNER9NAME > ADDRESS e CONTRACTOR / VSO-} CF Y271- RIONEL) 8LI-N' � SUBCONTRACTOR ADORE IJCF PHONE TYPE OF SEFTIC WORK: NEW INSTALLATION ❑ REPARIADMTION DESTRUCTION ❑ IND SEPTIC SYSTEM RRMITTED IF FUBLIC SEWER IS AVAILABLE MTHIN FERC TFSTLF)1 )IpW Apptlatlnn I Y7kiy10 INSTALLATION WILL SERVERESIDENCE COMMERCIAL EL-FI eVi-�I - ❑ OTHER ❑ NUMBER OF LIVING UNITS, NUMBER A�O1FB/EDROOMS: NUMBER OF EMFLOYFEI: [ CH ER OF SOIL TO A DEPTH OF G FEET:/{GLL)�.7.G- FEE/BUMP.SOIL CHARA TER4 X STATER TABLE OEFTH I LAL9 /f EL NKIOIIEASE TRAP ❑TYFE/MFO &) eL S Lli-WL✓�7�CAPACITY 1 LO�1. 1 1 NO.COMPARTMENTS COUNTY VK TMEMT RANT❑ DISTANCE TO NEMEST: N/ELL�Q_+- FOUNDATION _ FEIDPERTY LINE F PAS EMACES LIFE STATION❑ SIZE TYPE OF RUMP/ BAND OIL SEPARATOR IENCLOSED SYSTEM) NVIRONMENTAI HEALTH 0195ION LEACHING UNE B LENGTH OF LINES /Z-�-/L1 �r /lQ. DISTANCE TO NEAREST:WELL— /0 F FRORRIY LINE J! RLTEIL am WIDTH LENGTH DEFTH DISTANCE TO NEAREST:WELLFOUNDATION PROFERTY LINE MOUNDED -.�❑MDTH LENGTH DEPTH �'1 DISTANCE TO NEAREST:WELL'G�/y�� FOUNDATION PMPERTY LINEN SEEPAGE ATS pLUEPTH ;x / SIZE��NUMBER (9- DISTANCE TO NEAREST:WEaaFOUNDAMN�FRORRTY UNE _S SUMPS (❑MOTH LENGTH DEFEH DISTANCE TO NEAREST:WELLFOUNDATION FMRRTY UNE DISPOSAL PONOS ❑WIDTH LENGTH GEFTH DISTANCE TO NEAREST:WELL FOUNDATON PMPEREY LINE - I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BM JOAQUIN COUNTY.HOME OWNER ORUCENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE RISOPMANCE OF THE WORK FOR WHICH THI8 PERMITM ISSUED.1 SHALL NOT EMROY ANY FERBON IN SUCH A MANNER AS TO BECOME SUWECTTO WORKMAN'S COMRNSATION)AWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SONATUPE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE RRFORMANCE OF THE WORE FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMA.OY PERSONS SUBJECT TO WORKMAN'S COMRNS LAWS OF CALIFORNIA.' TNF AFP ANT MUST CALL 34 HOUIS IN ADVANCE MR AM REGURED INSPECTIONS COMPLETE DRAWING BBBEELO/WW.. SIGNED% TITLE: )/ DATE `�" 1"`04 V ROT PLAN DRAW TO SCALE)SCALE_ '- -IP I. NAMES OF STREETS OR MADE NEAREST TO OR BOUNDING THE RIORRTV. 4. LOCATION OF HOUSE SEWAGE DISMSSYSTEM OR RMMSED V Z. OUTLINE OF THE FMRRTY,WITH DIMENSIONS AND NORTH DIRECTION. S. OF SEWAGE DIdMBALSYSTEMS. G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND MOMSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUSSE OF ONE HUNDRED FIFTY ON INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALK$. THE PMRRTY OR ADJOINING FPoRRtt. aJ` 0 --awe- FS Pow, C �31 00 TRENT USE ONLY APPUCATON ACCEPTED BY W DATE: AREA-. TANK.FR OR SUMP INSPECTMI BY DATE I / FINAL INSFECTION BY ��(f/��DATE1 TIONAL COMMENTS: �� 1 ' r ✓\�La t 1 ACCOUNTING ONLY: AID, FACE PE CODE FEE INFO AMOUNT REMIITED CIIEC"ICA6H RECEIVED BY DATE MI RTMIT NUMBER INVOICE/ Pub.Heahh Sew -EnvirD. 174(3/96)