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9 DATE 4,1 Y -9)/ TITLE:621-71-1 -Th APPLICATION FOR L1CWID WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX Mt 445 N. SAN JOAQUIN ST., STOCKTON, CA 55201-0318 (209I 468.3420 DESTRUCTION 0 TYPE Of SEPTIC WORK: NCW INSTALLATION 0 REPAANADOTTION NO SEPTIC SYSTEM PERMITTF_D P PUMA': SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) ROR.REPONDADLE PERMIT EXPIRES I YEAR FROM DATE ISSUED /CompWs iiTripkata) APPUCATION IS HUM MADE TO THE SAN .60AIDUIN COUNTY FOR A PEANKT TO CONSTRIJcI ANELDR INSTALL THE WORK DESCRIBED. THIS APPUCATION IS MADE IN COMPUANCF WITH SAN JOAQUIN COUNTY DEVELOPMENT TJ55, CHAPTER 9-11 0.3 AND THE STANDARDS OF SAN JOAQUIN COUNT)" puBuC HEALTH SI:RACES. ENVIRONMENTAL HEALTH DiVESON 4-, JOB ADDRESSADR APNO OVVNER'S NAMEA_L \k/ A41/1._S ADDRESS PtY.Y1 PHONE CONTRACTOR IN ti,AtL g 3 .5c 4'.4!),g-91,04,51w 9.S.3-631 SUB CONTRACTOR ADDRESS UCE PHONE (12 ,9mip INTENULARON wILL BOWE: RESIDENCE 13.--63.-MMERCIAL 0 OTHER 0 NUAABOt OF UVING uNTTS- / NUMBER OP BEDROOMS •-",.?-1 NUMMI OF EMPLOYEES CHARACTER OF SOIL TO A DEPTH OF 3 FEET:.-- __ ,-, 7) PIT:SUMP SOIL CHARACTER --' A P50 17IEATMENT PLANT 0 DISTANCE TO NEAREST: 0 TYPE MPG fl/,J(' r.F.St.:5,,...".__ caeAcrre / ,)-(2rQ sEPTIC TANALOREASE TRAP DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY USE DISTANCE TO NEAREST: WELL FOUNDATION__„. PROPERTY ONE DISTANCE TO NEAREST: WELL /Pr" , ' FOUNDATION 4,14 PROPERTY UNE 1 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE____ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE -:7/ • FOUNDATION uFr STATION D WATER TABLE OEFTH NO. COMPARTMENTS PROPERTY UNE 1161/ WEU. PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) STU TYPE OF LENGTN OF LINES 0 WIDTH__ LENGTH__ DEPTH LEACHING UNE FILTER MD MOUNDED SELMA 01711 MAMA DISPOSAL PONDS DISTANCE TO NEAREST; WELL /00 FOUNDATION ..e.,"0" PRoPERTY LINE e/ in() LOT SIZE INADTH aor,prii LENaT IDVT/1 SIZE CAUFADEFI El WIDTH LENGTH DEPTH o WIDTH LENGTH DEPTH MC MATEO I ; NOW MANY ANollosSon I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK MU. BE DONE Al ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWN, AND POLES AND REGLILATIONS OF THE SAN JOAOLIIN COUNTY HOMEOWNER OR LICEEISED AGENT% ERGNATuRE cERTIREG THE FoNLOVANG: I CERTIFy THAT IN THE PERFORMANCE OF THE WORK FORWHICH TIGS PERMIT Is isp,UED, I SHALL NOT EMPLOY AllY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO INOPKIAAFFS COMPENSATION LAWS Of CAUFORMA.• CONTRACTOR'S HIEING OR SUB-C NG SIGNATURE CERTKIES DIE FOLLOWING: CERTIFY THAT IN THE PIRIRDISLEANcE of THE WORK FOR WHICH THIS MONT IS ISSUED, t SHALL EMPLOY PERSONS suSJECT TO WORKMAN'S mpENsATAON LAWS Of C FOR/IA.• THE ARROGANT MUST CALL 24 HOURS IN ADVANCE FOP ALL RECKERED INSPECTIONS, courirrE DRAWRIO PLOT PLAN YDRAW TO SCALE) SCALE I NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. OUTLINE OF THE PROPERTY, WITH DIMENSIONS Aid) NORTH DIRECTION. DIMENMONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS: AND WALKS. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED EXPANSION OF SEWAGE DISPOSAL BYSTEMS. B. LOCATION OF WELLS WITHIN RADIUS OP ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. Gs“ 19,§4 SAN .16;44y,,IN at:AC ..P1.411-1 EPi ^1,40NTAti-If.:ALTH dlt/81.0N Th ,z) Poll DEPARTMENT USE ONtY APPLICATION ACCEPTED BY TANK. PIT OR RAMP INSPECTION By AOID;TIONAL COMMENTS: I z_ DATE FINAL INSPECTION WY DATE: acCOUNTitla ONLY AIDS FADS PE CODE FEE IWO AmoUNT REMITTED c EcKs‘A.S). RECEIVED BY DATE SR I PERMIT NURSER INVOICE 0 4---2—t 1 4- 50 114 1 S AcJi ()Ok•k 6‘g 1 sX6S4 _ , .t,s -.en'i.ofeteee 'WA 4 , >re.iewzi • 11"1 NJ. VNI 17) )1. ‘4151..t, ... • • . .... . . . . . .. .. ... . . . . .. , o .