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APPLICATION FOR LIOUIO WASTE PERMIT Smv JOA0UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-988 (209) 4883420 + NON•REFUNDARIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complalo in MplkBt6l APDL IC AT UN 16 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 JOAOUI COUNTY DEVELOPMENT TfTLE,CHAPTER 9-1 R./1 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNN J 760 11��i�(p/ J �- I,✓" //'/� 1 CITY � z _ LOT SIZE OWNER'S NAME —IJ1 {' Cr_s �;�- In 2n2! ADDRESS d fF�'1!j ��/ �-Z- J .!1� ) ` r f � PRONE �4 •�2_, �' CONTRACIOfl 4J Ll �� ' ��, •f) ADORE 66 ��' J (_Y� �[ r�G*'f/`J L�-+ 1 1r �11 - J`Q/ LIC( L t ��G.f15PFiONE � 7H Cca SUB CONI RAC T OR ADDRESS uco PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPANVAODLTION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM PERMIT IED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.] PERC TESTI+I I f HOW MANY 2 APdloodon! INSTAt LATION WILL SERVE: RESIDENCE El COMMERCIAL ❑ OTHER ❑ NUMBER OF L1VIN0 UNIT 6: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES- CHARACTER OF SOIL TO A DEPT H OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASE TRAP ❑TYPEIMFG CAPACHY NO.COMPARTMENTS PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LEFT 67ATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI 1 EACHSNO UNE ❑ NO.LR LENOTIR OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER IEA ❑WIDTH LENGTH OEPfH DISTANCE TO NEAREST:WELL FT)UNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NFARFST:WELL FOUNDATION PROPETLTY UNE SEEPAgE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I RFRERY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULER AND REGULATIONS Of:THE SAN JOAQUIN COUNTY-HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I'SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO////MPfjNS A71ON LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED K.-�P /{j L^ [ �� . .L(� C �TITLE:_`L�// .c_—i'�) ��C''/� DATE: PLOT PLAN IDRAW TO SCALE(SCALE 'to 1- NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF RHE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTFMB. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PTLOPOSED SI RUCTUREB, S. LOCATION OF WELLS WURHN RADIUS OF ONE HUNDRED FIFTY FT.ON INCtUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS, AND WAIKB. THE PROPERTY OR ADJOINING PROPERTY. N . 2d w.. � I 47 3�Ye I.00PrY> 35 fy OCT 1 3: 1997 SAN JUAIXI44 COUNI Y PUPICIC HEALTH SERVICES C ENVIRONWEWAL HEALTH tIIVISIUN FOR DEPARTMENT USE ONLY AI•I'IICADON ACCEPTED BY �• DATE: AREA:�� TANK,PIT OR SUMP INSPECTION BY DATE ! ! FINAL INSPECTION BY DATE /0 ADDITIONAL COMMENTS: ACCOUNTING ONLY: ARU/ FACE PE COtlE FEE INFO AMOUNT REMITTED NEC ICASH RECEIVED BY DATE SR!PERMIT NLOM13M INVOICE