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APPLICATION FOR Liam WASTE PERMIT UUj-Ib U l SAN JOAQUIN COUNTY PUBLIC 'ALTH SERVICES ENVIRONMENTAL HEAL ))VISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (GmpMlf in Tr1pliBrtfl APPLICATION 16 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED, THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT/TITLE, CHAPTER 8-1110 J AND THE SSTTj/A/r�,DAnROB OF BAN Jy/AOx/V�COUNTY PUBLIC HEALTH BERVICtS.EN�VI,R0MMENTAL HEALTH DINBq N. JOB ADDRESS/O/R/APNI f% I/`/!✓/ ` -)✓ "o, /C/L/ CNY �l�'�`//O LOT SIZE OV.NEWBNAME�-F��/./�..., I`-�1/4F"L�.CSr/iC ADDRE6B/��"-t-z7f-G*.t I/r'Tt�/<LLC�7 �SZ-Zn 77 PHONE 63'O D CONTRACTOR" ' [ �L- /C_ ADDRESS/Z(C /�LLi(`Ir TT•/�` !,S Ln/ UC/ PHONE ' - 5 SUBCONTRACTOR ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATIONREPA1RJA.D11DON ❑ DESTRUCTION M ❑ IND SEPTIC SYSTEM PERTED IF PUBLIC SEWER 16 AVA UBLE WITHIN 200 FEET OF BUILDING.) PER.TESTI 1 I HOW MANY Appfaben I —j INSTALLATION WILL(EINE: RESIDENCE I�COMMERCIAI 11 OTHER C1 (NUMBER or LANG UMTS:_NUMB�19�00M�C�— IL NUMBER Of EMPLOYE1.2 V R OF 60TO A DEPTH OF]FEEL /6VMP 60IL.G{1�-1 ARACTEn�/r�4 WATER TABLE DEPTHTIC IOOREALE TRAP TYPE/ _ Sti.J. ^ CAPACITY �(np L`7 NO.COMPARTMENT MO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL(DC_^ FOUNDATION ' PROPERTY UNE fl LIFT STATION❑ SIZE TYPE OF PVMPSAND OIL SEPARATOR(ENCLOSED SYSTEMI �T� LEACHING LINE 'WNO.S LENGTH OF UNE. G>`� rLJ�i— DISTANCE TO NEAREST:WELLLG�C�r FOUNDATION �� PROPERTY UNE RITER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE � T SEEPAGE PITS �OEPTH�S ' SIZE 3&" NUMBER DISTANCE TO NEAREST:WELL FOUNDATON � ' PROPERTY UNE�1O SUMPS I-]MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ND THAT THE WORE(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGU NB OF THE BAN JOA WIN COUNTY.HOMED ERORLICENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PE IB BV EMPLOY ANY PERSO SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'B HIRING OR SUB-COI TRACT) G DNA URE E FIFO THE FOLLOWIN :'CERTIFY THAT IN THE PERFORMANCE OF THE WORK FDR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOW AN'S CO SA WS ALIFO T CALL 24 HOURS IN ADVANCE FOR ALL REOURED INSPECTIONS. COMPLETE DRAWING /BEEJLOW. -/-0 SIONE X TITLE: DATE' /✓ PLOT PIAN IDRAW TOSCALEI SCALE_ 1.NAMES OF STREET6 OR ROADS NEAREST TO OR ROUNDING THE PFO PER, 104.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSIONED OIITLINEe AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING flbl'ERTY. C¢ e ..... <..... ..i.. :...... ...i ..... ...i. � \ .._ ...... v .... .r. _. >......... �) ' ... .. - L.(2 ......... ocT 1 19ga fo ;_ NM T P�HEP E�VIRO E.SERVICES v..e l� PERMIT/ APTMENT USE ONLY AMICATION ACCEPTED BY DATE: U v AREA: T FAF♦�P 7 OR BUMP INSPECTIOH BYr ATE41 FINAL INSPECTION BY DATE ADDITIONAL COMMENTS:_ (7� A.CGUNIINO ONLY: NOI FACT PE CODE FEE INFO AMOUNT REW ITER C14EC CASH RECEIVED SY GATE M I PEFNUT NUMBER INVOICE y 1 3s 1 io 1 Pub.Health Serv.-Enviro.174(3/96)