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APPLICATION FOR 1.1010 WASTE PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SdAVICES ENVIRONMENTAL HEALTH DIVISION of R f 304 EAST WEBER AVENUE, STOCKTON, CA 95202 �'" (209)468-3420 NON-REFUNDABLE PERMIJ EXPIRES 1 YEAR FROM DATE ISSUED J J (Cempltte In Trlplinte) �.4 ��::/JJ �/ [P APPLICATION 10 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVI NMENTAL HEALTH DIVISION. .I JOB ADDRESSIOR AP`NO 9,3 0 cL- ._ _ �I-WeC��.- 1�-w'� CNy � LOT,SIZE��f" OWNER'S NAMEW/]��J - (6�--11 APIg 6L°O ADDRESS t+ _(• G PHO-NE CONTRACTORAU = ADDRESS (24 44V44?Jp{PNE Y 3 $US CONTRACTOR ADDRESS r �� LIC/ PHONE E TYPE OF SEPTIC WORK: NEW INSTALLATION) REPAIMADDITION © GFSTRUOTION E3IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER{g A J BLE WITHIN 200 FEET OF BUILDING.) PERC TFSTIO 1 1 HOW MANY t �7 .I APWesdoe t INSTALLATION WILL SERVE: RESIDENCE C+D COMMEIiC1AL❑ OTHER IJ , 1 1 y' NUM8ER OP LIVING UX3TS:- NUMBER OP SEDROOMS; NUMBER OF EMPLOYEES: / OF BOIL TO A DEPTH OF 3 FEET; t PITlSUMP SOIL CHARACTER. WATER TABLE DEPTI{ Leo 4" NO.COMPARTMENTS r S GR C TAN EASE TRAP ❑TYPElMFO �W CAPACITY ENT PLANT 13DISTANCE TO NEAREST: WELL F- FOUNDATION `t "F PROPERTY LINE it LIFT STATION©:612E TYPE OF PUMP r BAND OIL SEPARATOR{ENCLOSED SYSTEM) LEACHING LINE *NO.S LENGTH OF LINES W: "--4W I�V% DISTANCE TO NEAREST:WELL FOU NOATION aS" PROPERTY LINE 1©d T- ' FILTER BED WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE i MOUNDED `,❑�•VWNDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION_PROPERTY LINE SEEPAGE PITC PTH �'l BiZE, TI NUMBERDISTANCE TO NEAREST;.L t47OUNDATION `PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTYUNE DISPOSAL PONDS (3 WIDTH LENGTH DEFTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PItEPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIM COUNTY.HOME O WNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON SUCH A MANNER At TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB�ONiRACTINO SIGNATURE CERTIFIES THE F0110WING• CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHAD,EMPLOY PERSONS SUBJECT TO ` WORKMAN'S CO IGH LAWS C/WFORNIA.' TH CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGURED INBPECtIONS, COMPLETE DRAWING BELOW. SIGNED X TrTLE: DATE, "'� • 2-- TO ,TO SCALF)SCALE 'to I. 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 BEWAOE 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 A8 PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY, \ _ F - - - * �w P S i ;v ........ .....:... ... . � Lap, ..; � 31 .: s� . . .. ( c :.......... ......:....... :. ... .. ;..... .. ... w ,.mfr .....:/�✓�............. . -' _.... J FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY l DATE: &61OR SUMP INSPECTION BV 4 DA!aATE ;Q U FINAL INSPECTION BY ' 'DATE (prJ '�V 1 ADOITIONALCOMMENTB: .. C( or �.!/L�. -7 .r e- / 12 0iO ®Q / — ACCOUNTING ONLY: NOR FAC/ PE CODE FEE INFO AMOUNT RENO ITED ICIIEC lCABN RECEIVED BY DATE SR!PERMIT NUMBER INVOICE/ Pub.Health SerY•-Enviro.174(3/96)