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APPLICATION FOR L1111110 WASTE PERMIT PAYMENT RECEIVED S-114 JOAQUIN COUNTY PUBLIC HEALTH I .,RVICES ENVIRONMENTAL HEALTH DIVISION SEP B ZOOO 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH DIVISION (Complete In Tripl7eStel APMICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDNR INSTALL THE WORK DESCRIBED. THIS APMIOATION 16 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,C��1J(/�fER 0-1110`{.3 AND�TYEE-STANDAArS OF SAN JOAQUIN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVMO[�N//M(E/I{[//AL H�E�A�LTTHH DIVISION. , � C�" l, `�' ✓' � i'l 1 CITY r r tC/� LOT SIZE_ —JOB ADDRE88g11 APR/ y�� 7 �^- J )��y .. /� /I� �� /�j — OWNER'S NAME ADDRESS ,SEM l�'/ J / j-^�( �F (f/'/�/L.C� 177/Y� PHONE �7 CONTRACTOR ADDRESSI /� 111 LIC/ PHONE SUB CONTRACTOR ADDRESS l Y. ` l UCI RgNE TYPE OF SEPTIC WORK: NEW INSTALLATI REPAIMADDITION ❑ DESTRUCTION ❑ INO SEPTIC SYSTEM MRMT ED IF PUBUC SEWER IS AVAILABLE WITHIN ZOO FEET OF ILDING.) PERC TMTHI 1 1 NOW MANY AppYstlon I INSTALLATION WILL SONE: RESIDENCE❑ COMMERCIAL ❑ T. NUMBER OF WINO UMTS:_ NU MBOL OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER O/F��1� FIT/BUMP SOIL CHARACTER: WATER TABU DEPTH SFITIC TMTRUt ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKG 111FATM TT 1..I DISTMCE TO NEAREST: WELL FOUNDATION_ PROPERTY UNE LIFT STATION❑ WE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHING LINE ❑ NO.\LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PIgPERTY UNE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE own ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑MDT" LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE MW WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNEROR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLDWINO:*1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEglrt IBIS ,1 SHALL NOT EMROY ANV PERSON M H A MANNER AB TO BECOME SUBJECT TO WOR(MAN'B COMFFNSATION/AWB OF CALIFORNIA.' CONTRACTOR'S HIRIND OR SUB CO O GNATURE CERTIFIER TH 7`PLLOWINO: ERTIFY T AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEPiMR IB ISSUED.1 BHNL EMMOY PERSONS SUBIECT TO NOIKMAN'B C NB/A,TgN LAWS OF CAU SWIM.' THE 1 M UfT CALL 24110UW IN ADVANCE FOR Ap/LL,jI/R/AEC/URED�INySP//ECTIONL COMPLETE DRAWING BELOW. SIGNED MOT PIAN gRAW TO SCALE/SCALE_ 'IP 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PPOPOITY'. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUL11NE6 AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAL%S. THE PROPERTY OR ADJOINING PROPERTY. CcosQ , )c( cl& oti--ck4t � t1ca �� LMS (6,vi . r ....... FOR FPMf1AEl LMB ONLY APMICATION ACCEPTED Bv_ SII/ _ DATE•��ILCnL�T7�' ARE TMJ ��f TAM,.PIt OR SUMP INSPECTION By DATE / / FINAL INSPECTION BY l 4/e,l ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID, FAC, PECODE FEEINFO AAIOUNTREMHTED CIMECN/ dH REOEVED BY DATE M/PEVMIT NLMBEI INVOICE/ 22, - 2 --b �D023 'ub.HeaRh Se, -Enwo.174(3/96)