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APPLICATION FOR LIOUIO WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OIYISION P.O. BOX 388, 446 N. SAN JOACIUIN ST., STOCKTON. CA 95201.0386 (209) 4BB-3420 NOWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEP lComplrLE in T*IiatPl APPLICATION 16 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE-WITH SAN JOAQUIN COUNTY DEVELOP��M[[ENT TITLE,CHAPTER 8-1/110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADORES6,,AOR AAPNN 1:30 a a �C L Q^ r L-V``+ CITY 4ti LOT SIZEAL OWNER'S NAME V\ A..W%U-O t, {�� CQ,,,CjCt ADDRESS 2 1) ?vc k. L � �;� vc*L bv� PHONE �_ZG 2[-- Z-/6 Sj Q CONTRACTOR , e- ADDRESS P o. 13 a OIL k-6U-c- IIC,T PHONE d lJ 1 9 SUB CONTRACTOR ADDRESS LICK FMONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION IND SEPTIC SYSTEM PERM(TTED IF PUBLIC SEINER IS AVAILABLE WITHIN 20O FEET OF BUILDING.} PERC TEST[NI 1 1 WJW MANY Appllandan I INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER❑ NUMBER OF UMNO UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET; PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT[3 DISTANCE TO N�JRREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) _ LEACHING LINE ❑ NO.a LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUFiDATION PROPERTY LINE MOUNDED [3WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE` NUMBER DISTANCE TO NEAREST:WELL !LOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR:JCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT INTHE PERFORMANCE OFTHE WORK FORWHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY':HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM NSATION LAWS OF CAUPQRNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALI.REGURET INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE:_L'CP 4YC SL+ce DATE: PLOT PLAN IDRAW 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. 3. 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 t i .. A' n' VIRG6IMF� I T .......... ML ... a' . . . .. .. ...... . r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: 6 o 0 1 AREA; q TANK,PIT OR SUMP INSPECTION 8Y DATE ! I FINAL INSPECTIO DATE 1Q' ADDITIONAL COMMENTS; H ACCQUNTIN,O ONLY: AIDN FACT ©�fl � PE COfiE FEE INFO AMOUNT REMITTED CNECKaF ASH RECEVED BY DATES SR!PESMIT NUMBER INVOIC &f7-2,jG/4 2