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APPLICATION FOR LIOUI) WASTE PERMIT SArIV JOAQUIN COUNTY PUBLIC HEALTH Sg-ACES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DRTE ISSUED (Complete In Tflplkw) AP LCAT ION le IMRERY MADE TO TIIE BAN JOAGUIN COUNTY FOR A PERMIT 10 CONNMCT ANORG INSTALL TIIE WORK DESCRIBED. THIS RPI ICATION IS MAOF IN COMPUANCF WHII BAN JOAWIN COUNTY OEVELOINAfNT TALL.CHAPTER 8-111 O.7 ANO THE aTANOAr1Dt OF BAN JOADUEN COUNTY q/OlS HEALTH�KR�VEICTE6L.�ENVIIbNpMFNEAL HEAUII DIVIeION. JOB ADDEESBRR AM, 690 K/ F9e WIE2� gb FO. LjAT-)490P CA /CITY �{�f-n/ HR01 LOT SIZE 1� Ac OWNER'S NAME RII CHA R-D si-A4 my ADDRESS /� D BOX 77 F SIAM�� L Z'� ANIONS CONTIUCTOR VALLL� A4 C15-SEARGN ADDRESS 17. 0•BOK 3744 'rUXkt9cx llC• FINDNF 57a- 7948 SUBCONTRACTOR ADDRESS me %NONE TYPE OF SEPTIC WORK' NOM INST ALLATON ❑ NEVAIMADDIT1ON ❑ DESTREICl10N❑ INO SEPTIC SYSTEM PERMITTED If PLISUC SEWER 09 AVARABLE WITHIN 200 FEET OF BUIL MGM FERC FTESTNI I I NOW MANY_ / MPlle.ann F IN6TALlATIOM WILL SERVE: INE610ENCE❑ COMMERICIAL ❑ GINNER ❑ NUMBER OF LIVING UNITS: NUMBER OF SEDROOMS NUMROI OF EMPLOYEES: CHARACTER OF EOR TO A DEPTH OF J FEET: PTRUMP SOIL CHARACTER: WATER TABLE OEM SEPTIC TANKJOREASE TRAP ❑TYr tmea CAPACR V NO.COMPARTMENTS PRO TREATMENT MMT❑ DISTANCE TO MEATIEST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ BRE TYPE OF PUMP SAND OR SEPARATOR IEWLOSEO OYSTEMI LEACHING UNE ❑ NO.S UNEVEN OF LMR8 DISTANCE TO NEAREST:WEU FOUNDAYON PROPERry UNE FILTER SED O WRITH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE NTS ❑DETTH RAZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION POPERIYNINE DISPOSAL FONDS ❑YIRDTTI LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 NEARBY CERTIFY THAT 1 HAVE PREPARED TIES APPLICATION AND THAT THE WORK WILL RE TONE IN ACCORDANCE WITH BAN MACKLN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND WOULATIOHB OF THE SAN"AWIN COUNTY.HOME OWNER OR LICENSED AAEW'S&ONATURE CERTIFIER THE FOLLOWINO:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WOR(TOR WHICH TWO KMM IB ISSUED,I WALL NOT EMPLOY ANY PED ION M MICR A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COW RACTOR'S WARM OR SUB.CONTRACTINO RONATURE CERTIFIES THE FOLLOWING''I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 OVAL EMPLOY PERSONS SUBJECT TO WORKMAN'S CONFER ION"We OF IA.- THE APPLICANT MUST CALL 24 WHARS IN ADVANCE FOR ALL REUUBED INSPECTIONS. COMPLETE DIIAWINO BELOW. SIGNED% TITLE DATE: 2; PLOTMRAW TO SCAIEI SCALE_ 'IP 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDEN t4. LOCATION OF HOUSE SEWAGE dcnOSAL SYSTEM OR PMIOBED 2. OUTLINE OF THE PROPERTY,WITH DIMENOIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EX19TIM AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAWS. THE IAOPERTY OR AOJOIMNO FrOPERTY. w' 20 TN RD . 4 0 I2Ewr2T 1ZOAD (� �_ /. 1. V 1 rioPoStiV p BUr1,DIA.I(1 C ` PES SITI< \ PA"IlViE -1 rc-sT AEC 3 1997 -- - - 6Aol J' A—,)TJIA,[f'LlA11Y PUL'UC IIEALI'H,$kAVICES AN4ICATION ACCEPTEDB/V//� DATE: _ ` AREA: !Cl/�I /` q TANK.FIT OR SUMP INSPE4 y DATE / / FINAL INSPECTION BY DATE 2/ 1 O L ADDITIONAL COMMENTS:_ Q� C ACCOUNTING ONLY: AIDS FACT R CODE FEE INTO AMOUNTRNMII E 11EC /KASN RECENEDBY DATE BR/PERWTNU M INVOIOEE X21 OL�3-T 3L/ ']Pub.Health Sow.-EnAro. 174(3/96) 9 ✓ �