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APPLICATION FOR 1.111111!)WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION I <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> ROR•REFURDABLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUED <br /> ICanpht6 In Tripl estEl <br /> APPLICATION IB HEREBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVEL-ME TntE,CHAPTER 0.1110.3 AND <br /> THE BT 'OF BAN JO COUNTY PUBLIC HEALTH BEANVICEB,ENVIRONMENTAL HEALTH pNS1ON. J <br /> JOB AOOAE88lOR A r Tom' r �/ /c'RYy.��T% j, f`�3/� LOT e1zY �S <br /> OWHEWR NAM Lt/' /�eRSSe /J~J 7 'Al _ -_PHONE 8a&-o9 r <br /> OONTRACTOR Sr ADDRESS LIC/ PHONE <br /> BUB CONTRACTOR AOOIESS LICP RHONE <br /> TYPE OF SEPTIC WORK! NEW INSTALLATION❑ REPANVADOITION❑ DFYTRUCTIOM <br /> MO SEPRO SYSTEM PERMITTED F PUBLIC SEWER IB AVAnAGLE WITHIN 200 FEET OF BIRLDOIO.I + PE RC TESTI.1 1 1 NOW MANY <br /> /y/ t��H`JIL�1p�c APPBa.SBS. <br /> INSTALLATION Will.BENNE: RESIDENCE El COMMERCIAL L( OTHER❑ <br /> NUMBER OF UYINO UMTS: NUIME R OF BEDROOMS: RU VEIN OF EMPLOYEES: <br /> CHARACTER OF BOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTTR: WATER TABLE <br /> SE'FRC TANKIaREASB TRAP ❑TYPEJMFO CAPACITY NO.COMPARTMENTS <br /> PKo TREATMENT KAN�TI 13 pis FARCE TO NEAREST: WELLFOUNDATION PROPERTY LINE <br /> LFI <br /> T STATION El SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED RYBrEMR <br /> LEACHING LINE ❑ NO.B LENGTH OF LINES DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIDTH LENGTH OEPrH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LME <br /> MOUNDED Cl WOr1R LENGTH OEP V DISTANCE TO NEAREST:WELL,,,_„FOUNDATION PROPERTY LINE <br /> OEEPAOB PITA 17 DEPTH BME NUMBER DISTANCE TO HEARESTI WELL FOUNDATION PROPERTY LME i <br /> SUMPS 17 WIDTH LENGTH DEPTH DIRTANCE TO NEATEST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO REARM!WELL FOUNDATION PROPERTY UNE- <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WONK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OF"NANCEB AND STATE LAWS,AND RULED <br /> AND REGULATIONS OF THE BAR JOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT'S MONATIRIE CERTIHES THE FOLLOWING.•I CERTIFY THAT MTHE PERFORMANCE OF THE WOW FORYIBCH <br /> TMB PFFMIT n NUMD,1 SHALL NDr EMPLOY ANY PERSON M SUCH A MANNER AS TO RECDME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIPP O OR <br /> BUei:OTRMCir 9MNA CENTFKS THE FOLLOWING:'H CERTIFY THAT IN THE PEFFOFfAAHCE OF THE WORK FOR WHICH THAI PERMIT IS ISSUED,1 ONALL EMPLOY PERSONS WIBJECT TO <br /> WYOIRMA1f6 COMPENSAT WB pF C FINIS.' T AMIICANT MUST CALL?•TOURS IN AWANCB POR ALL REOIIIIED IMAPFCTIONB. COMPLETE DIVLWINO BELOW. <br /> WANED)IA TITLE: DATE e2= <br /> PLOT RAN(ORAW TO SCALE)BCAlE 'le <br /> 1.NAMES OF BTREEFB OR ROADS NEAREST TO OR SOUNDINO THE PROPERTY. 4.LOCATOR OF HOUSE SEWAGE OISPOBAI-"-I-OR PROPOSED <br /> Z.OUTLINE OF THE PROPERTY.WITH OIMENRONS AND NORTH DIRECTOR. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OURINEO ANO LOCATION OF ALL EMITTING AND PROPOSED STRUCTURES, e.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY PT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS.DMVIEWAYB,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. I <br /> ... <br /> ... `J <br /> 1 . <br /> 04 <br /> br of <br /> 1 <br /> . <br /> "� <br /> ., 1 e <br /> r <br /> df <br /> �. <br /> � . . l I IurQ�r�_ni!iah5 des un,,,,.. <br /> ...... <br /> �j <br /> ........... <br /> 4118K <br /> NVIf1QNtl7E <br /> .....i. .... <br /> ............ <br /> .. <br /> ............ .... ... <br /> Al/ <br /> FOR DEPARTMENT USE ONLY <br /> APPUCATION ACCEPTED BY Q DATE: ✓�r AREA! <br /> TANK,PIT OR OUMPiNSPECT N BY DATE 21. 1 FINAL MBPE N BY DATE <br /> AVORIONALCOMMENTS: /, - <br /> ACCOUNTTNP ONLY: ANP FACT ' <br /> R GO9E FFP INFO AMOUNTRSLBITm 1 ABH RECERFED BY DATE BR T P91MIT NtB m timms P <br /> -7 <br /> Ufa 1 <br /> PDD,Health SIN,-ETRdro.174 W96} <br /> A <br />