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APPLICATION FOR LIOUIU WASTE PERMIT
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> 304 EAST WEEDER AVENUE, STOCKTON, CA 95202
<br /> (209)468-3420
<br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER o!l (�_ 6 49
<br /> Ompl.Ti h Tdpllntel T I a,D-7 ae rQ
<br /> APPLICATION IB HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPUAW'E WITH BAN
<br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1110.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OMMON.
<br /> JOB JYDDR1E66/01?APNO CITYy'.OT SIZE p�--
<br /> OWNFA'6 NAME_ l' C/ ADDRESS Q�31� .� .���... R / � I �4
<br /> CONTRACTOR / L4J11 of CRESS LICE PIMJNE
<br /> SUB CONTRACTOR ADORESS LICE PI-IME
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION ❑
<br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.1 PE RC TESTIa1 l 1 HOW MANY
<br /> APPk&tF11n#
<br /> INSTALLATION WILL SERVE; RESIDENCE)ff COMMERCIAL❑ OTHER ❑
<br /> NUNRBT OF LINO UNITS:I NUklABE1 OF BEDROOMS: NUMBER OF EMPLOYEES:
<br /> CHARACTER OF BOIL TO A DEPTH OF 3 FEET: PITT P SOIL CHARACTER: d MtJf , WATER TABLE DEPTH_�l a
<br /> �cEEFTI0 TANKIG REASE TRAP g2 CAPACITY A NO_COMPARTMENTS'
<br /> ! PKG TREATMENT PLANT❑ DISTANCE TO NFA\EST: WELL�ODy FOUNDATION - PROPERTY LINE
<br /> UFT STATION❑ SRE TYPE OF PUMP SAND OIL SEPARATOR!ENCLOSED STEM! T _
<br /> LEAC14NO LINE �"NO_ LENGTH OF RJNEB^ DISTANCE TON WELL F.L ATION PERRY UNEP
<br /> RLTF91 SEp ❑WIDTH LENGTH_ DEPTH DISTANCE TO NEAIELUT:WELL FOUNDATION PROPERTY LINE
<br /> MOUNDED ❑WIDTH S^ � LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPEITTY UNE
<br /> tF
<br /> SEEPAGE FITS �'tSEPTH_1_\ L` NUMBER L DISTANCE TO NEAREST:WELL -FOVNDAT'K7N „r PROPERTY LIRE t
<br /> SUMPS ❑WROTH LENGTH i DEPTH DISTANCE TO NEAREST;WELLFOUNDATION PROPERTY LINE
<br /> DISPOSAL PONDS ❑WIDTH LENGTH —DEPTH DISTANCE TO NEAREST;WELLFOUNDATION PROPERTY LINE
<br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES
<br /> AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AOENT'B SIGNATURE CERTIFIER THE FOLLO ARNe:'I CERTWYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH
<br /> THIS PERMIT IS tBBUEO.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMNYS COMPENSATION LAWS OF CAUFGFWA.' CONTRACTOR'S HIIING OA
<br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR YWiICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO
<br /> WOFKMAN'S COMPENSATION LAWS OF CALIFORNIA,' THE APPLICANT MUST CALL 24 HOUNS IN ADVANCE FOR ALL REGLSRM INSFEOTIONS. COMPLETE DRAWING BELOW,
<br /> SIGNED X TITLE: Y �� � GATE;
<br /> PLOT PLAN(DRAW TO SCALL\SCALE Ie
<br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOINO THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSM
<br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.
<br /> 9, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON
<br /> INCLUDING COVERED MEAS BUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADMNNG PROPERTY_
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<br /> FOR DEPAJ! T USE ONLY
<br /> //APPLICATION ACCEPTED rry DATE: /11L�A:
<br /> OR SUMP INSPECTION BY DATE FINAL INSPECTION BY
<br /> ADDITIONAL COMMENTS:
<br /> ACCOUNTSYTi ONLY: JUDO FACE
<br /> iN:COD' FEE INFO AMOUNT R/3YBITEO G ASH RECEVEb BY PATE N111Y6@I INVOICE O
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<br /> Pub.Health Serv,-Envirro,174(3/96) 14� � — 3"l 2
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