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APPLICATION FnR LIOUIO WASTE PERMIT SAN JOAQUIN( ITY PUBLIC HEALTH SERVICES ENVIROt.-__NTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CompMb In Trlplk&td .PPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVMONMENTAL HEALTH OrVIegN. >B AOOREBB/Ofl API/ _ (r CITU 5`1 ISI - LOT SIZE WMER'8 NAME` 1 I�:.-I i 1�1,=ADDRESS )I.' `•Z �I��'J,1 (I.Ir(' PONE CONTRACTOR!. :(/ '�}.,I �i`:R I 0! ADDRESS - -'T�� N / 1 i LIC/ FHONE Bull CONTRACTOR ADDRESS UCF PHOHE IPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION❑ OFSTAm"ON❑ O SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF SUILDING.1 PERC TESTI.)I I HOW MANY INSTALLATION WILL SI IVC RESIDENCE❑ COMMERCIAL❑ OTHER❑ JM$6L OF WINO UMTS: NUMBER OF BEDROOM&: MUMBE 1 OF EMPLOYEES: IARACTER OF$OIL TO A DEPTH OF O FEET: PITIGUMP SOIL CHARACTER: WATER TABLE DEPTH -."C TANIUCRIUM1E TMP ❑TYPVMFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEMLEtT: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) ACHING UNE ❑ NO.t LENGTH OF LINES DISTANCE TO NEAR[ST:WELL FOUNDATION PROPERTY LINE TER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAMBT:WELL FOUNDATION P OPERTY UNE C� MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEARKST:WELL FOUNDATION PROPERTY LINE SEEPAGE PTS ❑DEPTH STZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SM ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE LIZ. SPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOVIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND F"VIATIONS OF THE SAN JOAQUIN COUNTY.NOME OWNER OR LICENSED AGENT'S WONATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFOIWANCE OF THE WORK FOR WITCH *NIS PERMIT It ISSUED.1 MALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORRMAN't COMPENSATION LAW$OF CAUTORMA.- CONTRACTOR'$HIRING OR is-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:T CERTIFY THAT IN THE PERFORMANCE OF THE WOEK FOR WHICH THIS PERMIT 18 ISSUED.1 MALL EMPLOY PERSONS SUBJECT TO DWMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 NOUIU IN ADVANCE FOR ALL R[GLIIRED INSPECTIONS.COMPETE DRAWING BELOW- SIGNED X TITLE: '�-�' DATE: - PLOT PUN DRAW TO SCALED SCALE 'Ie NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED MEAS SUCH AB PATIOS,DRIVEWAYS,AND WALXB. THE PROPERTY OR ADJOINING PROPERTY. CURE ROAD NOV b II5 % NV RO ENT &KDD' 5.00 A[RS Ell i tY34 t0Z iM pt1C81N FI/RIPS ^� t� f CIIST+.0 KMOIID OKI�LAD ' . �~ ii "D SIGMTED RfAWNDER" 117.2 E A:I S GROSS ' R FOR �OEPMTMENT USE ONLT �j,�J1 PLICATION ACCEPTED BY `�I I TWA-A'I'L DATE! I "T —A:—_" ,-W,PR OR BUMP MSPECTION BY DATE I 1 FINAL INSPECTION aV DATE I I ADDITIONAL COMMENTS: 1 Y�'H L.P\'r-Ei(iY1 1 ,l' -�-�' s l ("�.•` .r Y� �I,:Ur i.�l-�_ ..1•' ACCOUNTING ONLY: AID/ l71 FAC/ PE CODER FEE INFO AMOUNT REMITTED CIIEC K//CASH RECOVFD$Y DATE SR/►9KBT NIPM$91 INVDIC[/ Pub.Heafth Sere.-Enviro.174(3196)