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� LICATI08 FOR LIaUUl WASTE PERMIT C gmm. py SAN JuAOUIN COUNTY PUBLIC HEALTH SERVICES �� ENVIRONMENTAL HEALTH DIVISIONk0 304 EAST WEBER AVENUE, STOCKTON, CA 95202 I (209)468-3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompkti M TripUaata) APPLICATION 18 HERESY MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION Is MADE IN COMPUA14CIF WITH SAN JOAWIN COUNTY DEVELOPMENT TnLE.CHAPTER 8-1110.3 AND THE STAND 8 OF SAN JOAOUIN COUNTY PUBLIC HEALTH'ERVICES. RONMENTAL HEALTH DIVISION. JOB ADD RESB/OR APN! I/t.+' -1 CITY `^ � -� LOT SIZE � rt OWNER'S NAME l LI (�� L�_ ADDRESS �I ! /� /T� gq PRONE r �� CONTRACTOR �Y ADDRESS LIC! PHONE SUB CONTRACTOR ADDRESS LIC/ PHONE TYPE OF SEFTIC WORK: NEW INSTALLATION 13REPAIRIADDITION ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER ie AVAILABLE WITHIN 200 FEET OF BJ "' 6L-,4 PHtC TEST(Q I F HOW MANY // Applle�tfon! INSTALLATION WILL SERVE: RESIDENCE 1313 ]�COMMERCIAL❑ OTHER 1 t ��'v f�r /J .J/y NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ��I j t� �. rp 0�l� 0 T A r r� CHARACTER OF SOIL TO A DEPTH Of 3 FEET: PFT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKXI REAeE TRAP ❑TYPE/MFG CAPACFTY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE LIFT STATION© SIZE TYPE OF PUMP SAND OIL SEPARATOR tENCLOSEO 4YSTEMI LEACHINO LINE ❑ NO.A LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WICTI. LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEI PAOE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE Slu MpB ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WEU. FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDAT/0N PROPERTY UNE 1 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 REGULATIOMSOFTHE BAN JOAGUINCOUNTY.HOME OWNIEROR LICENSED AGENT'S SIGNATURE CERTIFIEBTRE FOLLOWING&'ICERTIFY'tHAT IN THE PERFORMANCE OFT"EWORK FO WHICH V THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN BUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMP@ISATION LAWS OF CALIFORNIA.- CONTRACTOR-11 HIRING OR . SUS-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWMIO:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S.COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW f SIGNED X TRLE:_ DATE: n I PLAT PLAN(DRAW TO SCALE)SCALE^ 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOBAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWAOE DISPOSAL SYSTEMS. �. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS AMAWALKS. .. ............ ....... .... ................... _,... ..,., ......... _ .. .-. ., ., . S. LOCATION OF WELLS THE PROPERTY OR ADJOINING PROPERTY. .. - - - - - - -- - -- i ...., ... .... ....... .... ..i. .: . ., _ ..... ... - .,. .... ... ]- ..... - - - - ... .,. ..., _ .,..... ...,.. .... ...... - ... .- .. -. ..:,.. ...;.,. ... ... . 7 ...., ...,.. .... :.......: r ...j..-. .... +EC u . I �. -.. ., .. .. .. - - .. ., - -. .. .. .. ED .... . _ . . FEB 5.20QQ SAN,/ LDA puix....., .., . C-NVIgpNMENTaL ... RVICE �7N ON .. .... ..... .. ............... ;.............:......_ .. FOR DEPARTMENY USE ONLY APPLICATION ACCEPTED BY �� GATE: CFC/ AREA: TANK.PIT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION by / DATE lzee ADDITIONAL COMMENTS:TI .C' =GY / ACCOUNNO ONLY: Alb! FAC! PE COVE FEE!NFO AMOUNT RBNISTED !CASH RECEIVED BY GATE SR P'@IMNB 1 IT NIaFli INVOICE Pub.Health Serv.-Er viro.174(3196)