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APPLICATION FOR LIOUIO WASTE PERMIT SAN-JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WESER AVENUE, STOCKTON, CA 95201 X88 j I209I 489.3420 �I NDR•REFURUABLE PERMIT EXPIRES I YEAR FROM PATE ISSUED ICBInPIlt! In Trolkalrl IiICAT{ON 18 HERESY MADE TO 711E SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTAR THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN AOUIN COUNTY DEVELOPMENT TfTLE,CHAPTER 9;1110.3 AND 711E STANDARDS OF SAN JOAQUIN COUNTY PUBLIC IIEALTH SERV) E8, VIRONMENT L HEALTH DIVISION. �hDORESSIOA APN8 /^ 1 L rt -, H1ER'8 NAME LOF SIZE 4' -" i - � ADDRESS �� •X j� PHONE `• y TRACTORJ 1 !7 CAbORESB ONTRACTOR / tic# PHONE 1/ ADDRESS LIC/ PHONE I PE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIRIADOITION DEB7RUCTION ❑ EPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF SU{LDING.I PpLC tlaTl•I{ I NOW MANY I ,p,� APP{InmHlon/ iTALLATION WALL SERVE; RESIDENCE IJ COMMERCIAL ❑ OTHER ❑J ' F71 OF LIVING UNI76:� NUMBER OF SEDROOMB• M ��^ ��"It�^� NUBEiI OF f3N PLO YEEO; ACTER OF SOIL TO A DEPTH Of J FEET: Plr18UMP BOOL CHARACTER: WATER TABLE DEPTH TI[TANK101lEASE TRAP ❑TYPEIMFq_1_`7L'I:�t`; L., a CAPACITY i !7nEATMENT PLANT❑ DISTANCE NO.COMPARTMEW 8 TO NEAREST; WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP----7- SAND OIL SEPARATOR 1EHCLOSED SYSTEMI ri .MND LINE NO.I LENGTtI OF LINED 7 DISTANCE TO NEAREST:WELL-Ivy - �_ FOUNDATION PfTOPEITTY LINE • !TER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ED er❑3S WIDTH LENGTH � DEPTH{ DISTANCE TO NEAREST:WELL14-DE PITS L7 6EPTH� SIZE__NUMBER I DISTANCE TO NEAREST:WELL ►Q T FOUNDATION PROPERTY LINE_ IMPS ❑WIDTH --h-- l FOUNDATION PnOPEItty LINE `�. IFNGTII DEPT It DISTANCE TO NEAREST:WELL FOUNDATION BAL PONDS WIDTHWIDTHLENGTH DEPTH DISTANCE TO NEARPROPERTY LINE EST:WELL FOUNDATION PROPERTY LINE 1 .BY CERTIFY THAT f HAVE PREPARED THUS APPLICATION AND THAT TI{E WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ID REGULATIONS OF TUE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSEE,AGENT'S SIONATURE CERTIFIES THE FOLLOWING;•I CERTIFY THAT IN THE PERFORMANCI OF TIIE WO11L FOR WHICH IIS PERMIT IS ISSUED,I SHALL NOT EMPLOY AMY PEn80N IN SUCH A MANNER AS TO BECOME SUBJECT TO WOIKMAN'B COMPENSATION LAWS OF CAtIFOnNIA,^ CONTnACTOR'S HIRING OR 0 RACTIHJG SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO MAN'S COMPENSATION LAWS OF CAL F"JOMM THE APPLICANT MUST CALL 24 I4OURO IN ADVANCE FOR ALL REQUIRED IrIBPECT1ONi, COMPLETE DRAWING BELOW, GF1Tb K C ? /�� ` [ �• TtttE• DATE: PLOT PLAN IDRAW TO SCALE)SCALE •1e } ...,MES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROT'ERTty, j OUTLINE OF THE PROPERTY,WITH4.DIMENSIONS AND NORTH DIRECTION. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PTIOPOSED TTIII��TTTIII DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, EISEWAGE DISPOSAL SYSTEMS. LUbINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALK$, B. LOO A CATIONTION OFF WELLS W[THIN RADIUS OF ONE HUNDRED FIFTY FT,ON �`-- PROPERTYTHE OR AOJOININq pROpERTY. I I HoA,; v L FOR DEPARTMENT USE ONLY -, 9�ItANUN AC I'IEd BY DATE: Z L t --- AREA:__7 �.�__... ,41TbRsump INSPECTION8Y lYlJ/ GATE ! I_ FINAL INSIjCTIDNBY II <,.�� DATE #� i r '� 4KAl COMMENTS: 6 rI rtQ � T rrS G T R A4QOIMt11N0$NLY: AID) FAC• ?I CODE FEE INFO AMOUNT REMITTED CHECKIlCASH RECEIVED BY DATE ER I PEIwIT NUFABLIi ..'� 3,. I•-l+`� H ry � INVOICE/ gtr�;a