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APPLICATION FOR UOUID WASTE PERMIT NO SAN JOAOUIN COUNTY PU13UC HEALTH SERVICES S� ENVIRONMENTAL HEALTH DIVISION 304 EA ST WEBER AVENUE,STOCKTON,CA 95202 (209)4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (GmplSb k TrIFBeBW APPLICATION IS HEREISY MADE TO THE BAN JOAOUHN COUNTY FOR A PEF949 TO CONSTRUCT ANDJOR INSTALL THE WOW.DESCRIBED.THS APPLICATION IS MADE W COMPLUWCE WITH TAN JoAOUN COUNTY DEVEWPMENT TrrLL CHAPTER S-1 110.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC NFALTN SERVICES, K HEALTH DIVISION.JOB ADORESB/OR APNO �01-a, �. � 'LP LV. -CITY �Y �� LOT S4Ev OWNER'S NAME A[IDIEBB �J+7r PHONE 2^y` CONTRACTORADOMSS LC! PHONE T `J SUBACTOR CONTRADDRESS UC! PHONE TYPE OF SEPTIC WORK: NEW NSTAuAnoM❑ REPAIR/ADDITION❑ DESTRUCTION EN ONO SEPTIC SYSTEM PEFI STT o IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) FERC roTw 1 1 NOW MANY App""-! INSTALLATION WALL SENA RESIDENCE❑ COMMERCIAL❑ OTHER❑ NNUUSM OF WANG UNITS: NUI.aER OF SEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SM TO A DEPTH OF I FEET: PIT/SUMP BOK CHARACTER: WATER TABLE DEPTH SEPTIC TANKMISS/LBE TRAP ❑TVPEANFO CAPACITY 140.COMPARTMENTS PALO TREATMENT►RANT❑ DISTANCE TO NEAFUT: WELL FOUNDATION PROPERTY LANE RIFT STATION❑ SIZE TYPE OF PUMP SAND O0.SEPARATOR IENCLOSED SYSTEMI LEACHING LINE ❑ NO.l LENGTH OF LINER DISTANCE TO NEAREST:WE31 FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH U 1MTN DEPTH DISTANCE TO NFA/EPr:WELL FOUNDATION PROPERTY UNE MAHJNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOIRAATKIN PROPERTY LINE SAGE RTS ❑DEPTH SRE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WW LENGTH DEPTH DISTANCE TO NEAREST:WUL FOUNDATION PPOPaTY LIE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION P"OPEMY LIME 1 HEREBY CERTIFY THAT A HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN JOAOUN COUNTY OIIONNANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER ORUCENIED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;-I CMTWYTHAT LATHE PERFOIMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON N SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENBAT'ON LAWS OF CAL"MSA"COMPACTORS WWA OR SUS-CONTRACTTNO SGIUTURE CERTIFIES THE FOLLOWING:I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHAM EMPLOY PERSONS SUBJECT TO wow.MAN'S COALPEN"TNIN LAWS OF CAUFOR IA.'THE APPLICANT MUST CALL 24 HOURS M ADVANCE FM/Alli.FAMM D DUpECTIONS.COMPLETE DRAW INO BLOW. SO f/ TTiZF: [ l LAK O l2� DATE: PLOT PLAN DRAW TO SCALD SCALE 'w I.NAMES OR 110/1D8 NIFAlESf TO OR BOUINOAIO TLE PROPERTY. 4.ROGATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2,O F 711E P110PEIfTV,WITH dMHAIONS ANO NOIRTN DIRECTION. EXPANSION OF BEWAOE OISPOI AL SYSTEMS. 7.DIMENSIONED OUnJNEB AND LOCATION OF ALL EXl6TING AND PROPOSED STRUCTURES, 6.LOCATION OF WELLS WITHIN RADKIS OF ONE NUNDFED FIFTY FT.ON NCLNDI G COWERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJONN0 PROPE/rrY. ..... - fDoDy�. ,. ............. ............ fq 1 4AM - ' f,:rtiN.i0NQU1NC:WnLY aavlAofudE1![TAL HFu7r avlsloTr .. FOR DEPARTMENT USE ONLY ASIA' au aha APPLICATION ACCEPTED BY ` SJ�``S" - WTE TMX,PR OR SUMP INSPECTION BY DATE I ADDITIONAL COMMENTS: ACCOUNTING ONLY: RIO! FACS K CODE FEE INFO AMOUNT REAITED CASH RECHVED SY GATE M I PEAT NSiER DNVOfCE! 6 I Pub.Health Sorv.-Em m.174(3196)