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APPLICATION FOR LIOUIO WASTE PERMIT SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICE§ ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209( 488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComploto in TrgOBBtel APPUCATNIN 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOW DESCRIBED. THIS AFPUCATION 18 MADE IN COMPLIANCE WITH BAN _ JOAQUIN COUNTY DEVELOPM�EENT TITLE.CHAPTER 8�-11`10.3 AND THE STANDARD8 OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. o JOB ADDREBBIOR APNI ' V 1 O—1 �J-� �� k�)l CJ' k- CITY L`14_'�i He�uYZT LOT 61EE, -,4 OWNER'S NAME /+ C,rff=aGZs 0)C ,L, ADDRESS 'PS ..7.-.N\is PHONE �}•'I T -�S�'Z� CONTRACTOR ADDRESS 11 S-14r K•Tr-,, tZ`\� L1CI .OM;-):J/ RHONE SUB CONTMCTOR ADDRESS LIC/ RHONE TYPE OF SEPTIC WORK: NEW INSTALLATION Ila REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO SEPTIC.SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF SUILDINOJ MC TEST(s)1 1 HOW MANY APNlwtlon I INSTALLATION WILL SERVE: RESIDENCE® COMMERCIAL❑ OTHER ❑ NUMBER OF UVINO UNITS:_ NUMBER OF BEDROOM/: NUMISER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF FEET:0I T]t4 PIT/BUMP BOIL CHAMCTER:nI(E� WATER TABLE DEPTH 7Y SEPTIC TANK/OREASE TRAP Iy F3TYPEIMFO '' nc' CAPACITY / c-Cc- NO.COMPARTMENTS PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELLJ 'j ' FOUNDATION - R 2 PIIOPERTY UNE /cf!y0 / UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENGLOBED SYSTEMI LEACHING UNE NO.B LENGTH OF UNE/ / �i� �t DIBTANCETO NEAREST:WELL 4!t FOUNOATION _PROPERTY UNE 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 RDEPTH ` SIZE `t NUMBER : DISTANCE TO NEAREST:WELL K5 FOUNDATIONJ�_ROPERTY UNE--/e--, H SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONDS ❑wKwH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE 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.ROME OWNER OR LICENSED AGENT'S SIGNATURE CEREIFIEB THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I&HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CLIFO ALIFORNIA.' THE APPLICANT MUST CALL 34 FOO IN ADVANCE R ALL RE IJBIM INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED% 1 J �Fh ( (^T.H.E" S\v '>� J< TRIS: /^,K.J :IN .i DATE: ��e .L7 C]V PLOT PLAN(DRAW 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 Z. OUTLINE OF THE PIWPERTV,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED BTRUCTUREB, 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. L _ V U IV R SEP 2 4 1998 F- UJ C.UtlTYN ' (l--C. PULIHFALTt�SERVICE,.. ..