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APPLICATION FOR LIOU10 WASTE PERMIT I t ! SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION r P,O.BOX 888,304 EAST VVEBER AVENUE,STOCKTON,CA 95201 968 E {209)469.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Trgliemti) 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 COUNTY DEVELOPMENT TRUE,CHAPTER 8-771 Q3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES..ENVIRONMENTAL HEALTH DIVISION. yJF"'I'll"I'll" JOS ADDRESS/DR APN/ T 3 z t �/ fr.��.J.L,�-4�' �� IS QI(fC.r/ �'7/ LOT SIZE -OWNER'S NAME1 ADDRESS ' CONTRACTOR� � �JJ�/>9'Ir+rIUURE88 n LICE /J' L�7 PNOHFJS `I/{�j SUB CONTRACTOR jS_ ADDRESS UCN T7��! PHOkE TYPE OF SEPTIC WORK: NEW INSTAE ATION REPAIRIADINTION ❑ OE6TRUCTION❑ IND SEPrK;SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PIRG TEST.,I I HOW MANY �J �yAPPPaeB..f NSTALLATPON WILL SSIVE: RESIDENCE E03 COMMERCIAL COMMERCIAL❑ OTHER AW,61 rho � •�HUMBER OF UVINO UNITS; NUMDER Or BEDnOOMP: MUMS OR OF D"PLOYEES; CHARACTER OF BOIL TO A DEPTH OF 3 FEET: PRIBUM^P'BOILIL CHARACTER: /- WATER TABLE DEPTH EPTIC TAN EASf TRAP ❑TYPFRAFO 7 !'L —IIA. UA-CAPACITY I�� 7/ J1 _ NO.COMPARTMENTS! NLa TREATMENT IR11NT❑ DISTANCE TO NEAAFeT; WELL FOUNDATION PRDPERTY UNE j UFT BTATON❑ SITE TYPE OF PUMP BAND OIL SEPARATOR IENCLOSED SYSTEM) k LEACNINO UNE ❑ NO.8 LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I` FILTER BED p WIDTH LENGTH DEPrH —F- DISTANCE TO NEAREUT:WELL FOUNDATION PROPERTY UNE IT AOVN0- ❑WIDTH LENGTH DEPTH DISTANCE To NEAREST;VfELLFOUNDATION PROPERTY UNE EEPAOE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST;WEU. FOUNDATION PROPERTY UNE ` BL7MPi ❑WIDTH LENGTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION 7TIOPERTY UNE Iy�DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE 10771 WILL BE DONE IN ACCORDANCE MTH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ND REOULATIONS OF TME SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WOW FOR WHICH HIS r1RM1T 16 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AB TO BECOME SUBJECT TO WORKMAN'G COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR `7 BUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOrKMAN'B COMPEN ION LAW$OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGGREO INSPECTIONS" COMPLETE DRAWING BELOW, F�..IDTITLE: DATE: 3 PLOT PLAN IORAW TO SCALE)SCALE .Ic 7Y i T,NAMES OF STREETS Oq ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTTM OR PROPOSED OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMB. 3 OIMENSIONED O[nLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF VA"WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON i INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WA-8. E PROPERTY OR ADJOINING PROPERTY, - I/y 4041. 'Pal }JI .. .. ;n .. .. . .. . _.... .. P f .. f . . ... ..... %.F7Y . I ..... ....... ......... ...... ....... ......... ... — - -- 4 1.0 .......... T I FOR DEPARTMENT USE ONLY ry �j Imo, rll.ATI.N ACCEPTED BY DATE: AREA: •+'nNK,PR OR SUMP INSPECTION BY DATE_____L I FINAL INSPECTION BY -e DATE^��'T I/L) - E ADDITIONAL COMMENTS: F� y12r { r I`LL PP i ,—ACCOUNTING ONLY: AID# FAC/ PE CODE F AMOUNT REMITTED CHEC K11CAS11RECEIVED BY DATE SR I PERMIT NUMBSR INVOICEP