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APPLICATION FOR UgglD'WASTII �-PUBLIC HEALTH SERVICES j SAN JOAOUIN COUNTY,PUBLIC HEALT +4 DIAL HEALTH DMSIGN06U&1 9 NMENTALHEALTH DNISIO ENVIRO �� PERM t 304 EAST WEBER AVEN:U j,i$TOCKTON, C 1 (209)488=3420 NON•REFUNO BLE F Nil EXplilES' LRF DATE SSU D 1�trH N (Clmpkto,In Millelp).' FLE t I P n Pv APPLICATION 18 HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. TWO APPLICATION JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1110.E AND THE STANDARDS��+�aRN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH1_OT S12E 'L CITY JOB ADDRESSrOR APNf / ,//�+^ CD PHONE ~ r7 OWNER'S NAM �� - -4 "�' '�� ADDRESS e f L�f �uZ2}r PHONE / 1L�C?N �J� rJ •��G, ADDRE66 � >f•�� Rf 1 Vr . CONTRACT O L1G f��_PHONE___, ADORES elle CONTRACTOR l PIEPANVADDITION AFlTNucnON }YPS OF GEPTIO WORK: NEW INSTALLATIOFI ❑ PERC TBSTtgl I I NOW MANY ' jN0 BEPFIC SYSTEM PERMr TEO IF PUBLIC SEWER 18 AVAILABLE 200 FEET OF BUI No.] Appll>KdOn INSTALLATION WILL/k'AVE: RESIDENCE E3 COMMERCIAL LL_J�! OTHER I� NUMBFII OF BEDROOMS' NUMBER OF EMPLOYFFA: � NUMBER OF U%RNO UNITS ;- ATER TABLE DEPTH CHARACTER OF SOIL TO A DEPTH Of 3 FEET:!/ _PRI$UMP SOIL CHARACTER LY' ' CAPACITY NO.COMPARTMENTS SEPTIC TANKMALUE TRAP Ia TYPE/MFO PKO TREATMENT PLANT❑ DISTANCE TO NiMEST: WELD„ FOUNDATION— PROPERTY UNE UFT STATION❑ SITE�,�,�.TY OF PUMP SAND OIL SEPARATOR(ENCLOSED SYBTEMI I LEACHING LINE ❑ N0.&LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE�� raLTl91 OED ❑WIDTH LENGTH CPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNEP 6 DEPTH DISTANCE To NEAREST:WELLFOUNDATION PROPERTY UNE��. MOUNDED ❑WIDTH LENGTH PROPERTY UNE SIZE_NUMBER DISTANCE TO NEAREST:WELL FOU SEEPAGE �_�- SEEPAGE PIT! I3 DEPTH- _ C r /mow F PROPERTY UNE BUMPf WROTH � f -LENGTH�J& _DEPfH„$�DISTANCE TO NEAREST.-WELL SLL�FOUNDATION k FOUNDATTDN� PROPERTYLiNE��^. DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WLT11 BAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND MUS AND Tg.11OFTHE BAN JOAQUINCOUNTY HOME OWNER OR LICENSED AOENT•SSIGNATURECERTIFIEBTHE FOLLOWING-•10EISTIFYTHATINTHE PEIFORMANCEOFTHEWORKFORWHXIi THI 18 ffi ,1 SHALL NOT EMPLOY PERSON IN SUCH A MANNER AS TO BECOME BUOJECT TO WORKMAN'O COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S IIIR M OR a SU 0 [ N CERTIFIES THE OWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 195M,I SHALL EMPLOY PERSONS SUBJECT TO I FKMAN• CO T W8 OF CALIFO THE APPYC T MUST CULL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION!, COMPLETE DRAWING BELOW C! SIG X SAD A-,-C TITLE: DATE v Is i PLOT PLAN(DRAW TO SCALER SCALE •to fr 1. NAMES OF STREETS ADS 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 SEWAOE 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 ADJ RMO PROPERTY - -- - - - p � -. -.. --.. ........ i. .- - .. .. ...:.... wM Chi INTY pug .....i ....i..... .i....e..,. ., ........ .. .. :... ..: .... .. ... ....... : .. .. ... - .. . ...........:......E... .. .. .. .. .. ... t .....;........... ........ ., .. .. .. .. .. .. .. .. .. x, •' El ., .....',... ..'......:..... .. .. .. .. .. .. .. .. .. . jI. .. . 61 ......, ..........:......' .:...:.............. .... .. .. .. _ �R DEPARTMENT USE ONLY APPLICATION ACCEPTED BYsokv— DATE: �hl A: - I TANK,PIT OR SUMP INSPECTION BY DATE I 1 FINAL INSPECTION B may" I ATE ) Q k ADDRipNAL COMMENTS: ��S h �' t� "��• / I I O r -2/ 1 , ACCOUNTING ONLY: AMP FAC* - PE CODE FEE INFO AMOUNT PLUMATED ICABN RECEIVED BY DATE SRI Pam NUM8B1 INVOICE f Z 2�0 rz(o o S-b 77TZ1. D o/0 Pub.Health Serv.-Erlvira.174{3/96}