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r PLICATION FOR Liam WASTE PERMIT SAN- AQUIN COUNTY PUBLIC HEALTH SEES 60 0 3 ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CompMta in Triplicate) Vv Ar- A APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT:TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADENCE WITH SAN JOAQUIN COUNTY DEVELOPMEENTTTTITLE.CHAPTER 8-11100.3 ANND THE 9TAANOAROB OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESENVIfgNENTAL HEALT J06ADORE8B/OR APNf 3+, �z (moi/ /G'�T--G� _CITY /✓l`�6 L� -_--- _- - -LOT SIZE OWNER'S NAME t C, /-/v Cc� ADDRESS �'�7/Trl'�L l.J' PHONE CONTRACTOR `C�7// ��j ADDRESS� G`,�' �G SGI� L1C1 S/ PHONE SUB CONTRACTOR ADDRESS LICE PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITRON ❑ DDEESTT�RU�CTqTO _ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.1 /7/ � PERC TESTIA 1 1 HOW MANY INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL,❑ OTHER ❑ NUMBER OF LIVINO WETS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET:_ PITlSUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKAIRE LSE TRAP D TYPEIMFO .CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT© DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING LINE 13 NO.&LENGTH OF LINES ''DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER - DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS 0 WIDTH -LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE DISPOSAL PONDS Q WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAl2UIN COUNTY ORDINANCES AND STATE LAWS,ANO RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNERORLICENBED AGENT'S.SIONATURE CEKTIFIESTHE FOLLOWING:'(CERTIFYTHAT IN THE PERFORMANCE OF THE WOFK FOR VA41CH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIMM OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE WOPK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA.' THHEApJ9GC�ANT MUST CALL.24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS. COMPLM DRAWING BELOW. SIGNED X TITLE: (! DATE: —� 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 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. " EXPANSION OF SEWAGE DISPOSAL SYSTEMS. O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. 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. 1 _ -- - .... ... y .....,.. ..... .1....... �...., ...�.. ..... .. - -,- ....i ...,: .... .............. .. ..... ...... .. . .. .. .. , :..... . :...... ....:. .. :............... .. ......... :..... . :..._. ........... . ... :.....; .. .. .. .. .. .. .. .. :.... . .... ....: . , I ..... .............: .. .... ..... .. . . ... _SAN JOAQUIrl CQUN- � 4+C rV...;. .FG...i��. .....cllVf�t7 J4 hti.1LHFr14Ik(Cal 7 "d F 1 DEP T USE ONLY r--- - APPLICATION ACCEPTED BY _ _ DATE: AREA: li � TANK.PIT OR SUMP INSPECTIO14 BY DATE ! -_.1.- -_FINAL INSPECTION � DATE ADDITIONAL COMMENTS:' r �C dii ACCOUNTING O}OLY: AIDE FAC.) PE CODE FEE INFO AMOUNT REMITTED CHECKf BH REC&M BY DATE SR I PERMIT NUMBER INVOICE f C >t Pub.HeaRh Serv.-E nviro.174(3196) �"