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APPLICATION FOR UaIJla WASTE PERMIT / SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 W— Jj 7 /J� NON•REFURDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C� �0•� IceRp1,I,In Trp&aEE) APRICATION IS HEREBY MADE TO THE SAN J0AOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WOW DESCRRIED. THIS APPLICATION IS MADE IN COMPUANCF WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 0-1110.3 AND THE STANDARDR OF SAN JOAOUIN COUNTY PURUC HEALTH BEIlV1'CnEe.�FNVIRDNMENTAL HEALTH DIVISION /�'�T�'"��/� JOS A]DREU-POR APNF �tib 1 `` I� CRY �`�—yam t LOT SIZE 1 L r rc F � OWNER'S NAMF�Y��yC� Z ADOnsss 7L"'1'"�C_ FrwNe ,S`•Ol I�1 - CONTRACTOR ADOIESS LUCF PHONE PUB CONTRACTOR ADDRESS UC/ PHONE TTPE OF SEPTIC WORIL: NEW INSTALLATION REPARUADDITION❑ DESTRUCTION❑ SIO SEPTIC SYSTEM PEHAGTTEP IF PUBLIC SEWER 1S AVALABLE WI11UN ZOO FEET OF BUILDING.) PEEK TESTY(I I HOW MANY AppSeRYPn INSTALLATION WILL SERVE: 11FSROFNCTX COMMERCIAL UOTHER 11MlAiim OF LAYING UNITS:_ / NUMS61 OF FEDFIOOMA��_NU1,01M OT OMPLOYTES: CHARACTER OF SOIL TO A DEPTH OFF 3 FEET! ^�'TW,.PrTISUMP FOIL CHARACTER: WATER TABLE DEPTH MtL- C- �I *ERIK TANRIORFASE TP y�Tlrvmm�• - CAPACITY D� NO.CUMPARTMENTS �- PKO TTIEATMETIT►Ur-HT 11 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE D LIFT STATION SIZE TYPE OF PUMP SAND OIL 6TPARAI OA(ENCLOSED SYSTEM( LEACHING UNE ''JYF'-��'NO-A LENGTH OF LINER ;— l(�iT DISTANCE TO NEAREST:WELL RLI FOUNOAMN PROPERTY UNE FILTER SED IJ WIDTH LENOTH DEPTH DNRANCE TO NEAREST:WELLFOIROATION PROPERTY UNE MOUNDED ❑WIOTM LENGTH DEPTH DISTANCE TO NEAREST:WELLTOUNDATION P"OPERTY LINE ■mAOE PRS ❑DEPTH SITE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WEIL FOUNDATION PROPERTY UNE DISPOSAL PONOS ❑YADTH LENGTH DEPTH 04STANCE TO NEAPIEST:WE11 FOUNDATION PROPEKrY URIE I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATIONAND THAT THE WVFA[MU BE DONE M ACCORDANCE WITH SAN MAQUIN COLMTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS DF THE SAN JOAOVW COUNTY.NOME OWNER OR LICENSED AOENT'S SI[INATVRE CERTIFIER TETE FOLLOWINO:"I CERTIFYTHAT IN THE PEIFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS PERMIS ISSUED,1 WALL NOT fWWLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORPRA.- CONTRACTCR'E HRENG OR SUS.CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT M THE PERFOIRMANCE OF THE WOPR FOR WHICH THIS PERMIT R ISSUED,1 SNAIL EMPLOY PERSONS SUBJECT TO WOEIKMAN'S COMPENSATION LAWS OF CAUHIWSA."THE AP ICANT MUST CALL 3 HOURS PR ADVANCE FOR ALL RECLAIMED INAFECMONS. COMPLETE DPAWTHG SELOW. B10NED X� ✓ ` TITLE: �)L�'�1�L PATE: PLOT RAN STRAW TO SCALEI MALE.'to I.NAMES Of STREETS OR ROADS NEAREST TO OR ROUNDING TIPS PROPERTY. 4.LOCATION OF HOUSE SEWAOE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE RRDPERTY,WITH DNMEWSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPC EO STRUCTURES. 6.LOCATION OF WELLS WITHIN F A E OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK$. THE PROPERTY OR ADJOINING PROPERTY. \J Y.: ..TY . .. ... ......... .... ........... ... : • F�T ........ .........:...:. ..i. ............. ... J G -17 _ ........,..... ` : .............. ...... ............. ........... ...:....... ........ .. LA• MIA., .. ..... .. ... ` FOR .TMfT1Y UEiONLY �•` �� APPLICATION ACCEPTED BY C[ � � DATE: l �� AREA: J TASK.PLT OR SUMP IN"CTIfLf DATE 1 —Al INSPECTION BY DATE G�1/U ra fj5` S_ronJ 5 r4�K ws�A ADPRIO NAL COMMEM9._�• AGOOUNTTNO ONLY: NDE FAC/ ECOOEPHWFO AMOUNTRFNIIITED ILECKF ASH RECEIVFD SY DATE SR MII PERT"%^a 1 INVOICF F Pub.H994h SEN.-EnvirC.174(3196)