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APPLICATION FOR LIOIIIO WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WESER AVENUE, STOCKTON, CA 95202 (209)468-3420 lrOM•RUMABLE PUNT EXPIRES 1 YEAR FROM DATE ISSUED (CampMt6 M Triplieaul APPLICATION 19 HERESY MADE TO THE SAN JOAORRN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED_ THIS APPLICATION 18 MADE IN COMPUANCF;;ATH SAN JOAGIHN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERME6.EN1gRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI - �J J -1 y e' �� r f .6 _ _CRY �'h l�fC LOT&2E�� OWW PIER'a NAME_ -, 'A� -. ^i 7�' PHONE_ CONTRACTOR - ADDRESS LICA PHONE W,M Bve cONTRACTDR ADDRESS LICA C410NE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIPJAMATION DESTRUCTION❑ M SEPTIC SYSTEM PERMITTED IF FVBLIC SEWER,8 AVAILABLE WITHIN 700 FEET OF bUb.DBVGJ PERC TESTNI 1 I WJW MANY APp�SpA✓<�_ � __ INSTALLATION WILL SERVE: RESIDENC\'o COMMERCIAL❑ OTHER E3 NOMMEN OF LMNG UNITS: NUMBER OF 6EURODUB: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET:� 6 Dl7,i of PITISUMP SOIL CHARACTER: r. WATER TABLE DEPTIj- IEPnC TANKIAREASF TRAP ❑TYPElMFa 4 CAPACITY ,�/ NO.COMPAI T!01ENTB PKO TREATMENT PLANT❑ DINITANCE TO NEARVIT: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP BvyANND.OIL SEPARATOR(ENCLOSED SYSTEM) LEAC14NO UNE ,IyL�+, NO.S LENGTH OF LINES Z— (IBTANCETO NEAREST:WELL 50'"r"�M N �PROPFRTY LINE FILTER Bm LJ WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE A MOUNDED O WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FUUNOATION PROPERTY UNE SEEPAGE PITS 0 DEPTH812E _NUMBERDISTANCE TO NEAREST-WEZ�AUNDATION PROPERTY LINE SUMF6 XI WIDTH LENGTH� DEPTH_,DISTANCE TO NEAREST:WELL_LQb____FOUNDATION PROPERTY LINE DISPOSAL FONDS ❑WIDTH LEMGTN _DEPFH DISTANCE TO NEAREST:WELL _FDUNOATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH IAN JOAQUIN COUNrY ORDINANCES AND STATE LAWS,AND RULES �J AND REGULATIONS OF THE BAN JOAOUIN COUNTY-IWME OWNERORUCENBED AOENT'e SIGNATURE CERTIFROTHE FOLLOWING:*1 CERTIFYTHAT INTHE PERFORMANCE OF THE WORUFOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN-6 COMPENSATION L.AWiE OF CALIFOIWIA.• CONTRACTOR'S ME4fMS OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOH WHICH THIS PEFMR IS 196M0,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATI,OM LAWS OF CAUFORNIA,'/THE APPLICANT MUST CALL 24 HOURS I"ADVANCE FOR ALU REGI#�RED INSPVCTWN6. COMPLETE DRAWING BELOyW, SIGNED% !r!J �L� 7TflE:_ f wleiT+�^K'*-TA.t� DATE: PLOT PLAN IDRAW TO SCALE)SCALE! 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL 6YeTEM 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, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJONNING PFIIW@NrY. _ — A it ON : .. s �-t6P Vic„+ Wil..... W25 Snry JdtictuiM r L+B1.1C!-il=y€TH$�RVEC�S N1tiEJ�T,q�-p4EAj TW UA FDR DEPARTMENT USE ONLY � ] APPLICATION ACCEPTE?T10 DATE: �~ /`��`-� _ AREA: TANK,PIT OR SUMP/NSDATE 1 1 FINAL INSPECTION BY DATE. 1 1 AOOGTIONAL COMMENT ff=CC0,U"NNG ONLY: AID/ FAC# E FEE INFO AMOUNT KIMIITED ITEC /CASH RECdWIFbSY DATE SR I PERMIT WINNEER INVOICE F Pub.Heats Sarv.-Enviro,174(3196)