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APPLICATION FOR,IIQUIO HASTE PERMI SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I Z 3L' ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.0388 C(Opy (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. .4104 2yS--220_03 n p Job Address/or APN# 20 97[/ 5, LNR OL 7-0 1-/ 4 "2D City ,40^ O Lot Size U 4ejoS Owner's Name c./-1/&IC/l/Oc-U Address_24F fL X/lam A), //°�^,/�. Cq Phone5l�--Z927 Contractor/VC/1— 0. AVOe2f/,.-/#43101-, Sn/C Addressl2 N. flAi177)^/L�/� Z4Lic# `YY41% Phone.167-,?7c71 Sub Contractor Address Lic# Phone TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION l 1 DESTRUCTION I i PERC TESTWX Now man (NO SEPTIC SYSTEM PERMITTED iF PUBLIC SEWER IS AVAILABLE WiTHIN 200 FEET OF BUILDING.) 9 Land Use Application 3a l 5 Installation will serve: Residence Commercial Other Number of living unitss Number of bedroomes Number of employees: Character of soft to a depth of 3 feet: Plt/Sump Sol( Character: Water Table Depth SEPTIC TANKIOREASE TRAP II Type/Mfg Capacity No. Compartments PKG TREATMENT PLANT L I Distance to nearest: Well Foundation Property line LIFT STATION() Size Type of Pump Sand Oil Separator (enclosed system) _ LEACHING LINE ❑ No. 8 length of lines Distance to Nearest: Well Foundation Property Line FILTER BED 0 Width Length Depth " " Well Foundation Property Line MOUNDED 0 Width Length Depth " " Well Foundation Property Line SEEPAGE PITS 0 Depth Size Number " " Well Foundation Property Line O SUMPS () Width Length Depth " " Well Foundation Property Line —9 DISPOSAL PONDS 0 Width Length Depth " " 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 licensed agent's signature certifies the followir>sop : "I certify that in the performance of the work for which this permit is issued, 1 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 that in the performance of the work for which this permit is issued, I shall employ persons subject to workmsa compensation taws of California." 1P The applica7mucs11 2t hour�nc• for all required inspections. Complete drawing below. //�� Signed Xt�, TItIe:/ 2ot�?'0, Date: 2 3 AS 1 PLOT PLAN (Draw to Scale) Scale " to O 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or A- 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage disposal systemsO 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on� structures, including covered areas such as patios, driveways, the property or adj0lnin property. and walks. C _l2v til o ii� l_Oc/'<ricl� "l.l F �> FOR DEPARTMENT ONLY Application Accepted by Date: Tank, Pit or Sump Inspection by Date / / rFinal Inspection by ( Date J- Addi ion l Comments: �) I-is f �L�, (I�/v'G 1 71 ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED EC CASH RECEIVED BY UAiE SR I PERMIT NUMBER INVOICE I