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APPLICATION FOR UOUID WASTE PERMIT S ! JOAQUIN COUNTY PUBLIC HEALTH S'15RVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED M ompled In Triplicate) APPLICATION IB HEREBY MADE TO THE BAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT MDAR INSTALL THE WORK DESCRIBED. THIS A ATION IB MADE IN COMPLIANCE WITH BAN JOAOUIN COUNTY DEVELOPMENT TITLES.CHAPTER 9-1110.33 AND THE STANDARDS OF SAN"AWN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH OIWSION. JOB ADDRESBAR AFI, /O /-�jI GV./J!"/C-E(.!/�/�T C�6/' I T cnT � TAY K�� P LOT SIZE_// OWHER'S NAME /F Y// C�A��`R=/ ADDRESS �EO 7 / �Ll'� L �r 4?t R10NE /p/J.:z S�Y CONTRACTOR i /t-//C/� O'/L_ ADDRESS /3 / 7/1 P DICE ry/ r/1Z PHONE T� 5 BUB CONTRACTOR ADDRESS LIC, RHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAim"INTION N DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) FERC TTSTNI 1 1 HOW MARY // / Appeseen INSTALLATION WILLBERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ !15/J.K I' �Ize NUMBER OF LINO UMTS:_ NUMBER OF SEDROOMS: NUMBER OF INIMOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: ., /LQL> PI))TISUMP SOIL CHARACTER: WATER TABLE DEPTH zLJ SEPTIC TANKAIREASM E TP ❑TYPEMFO ��A-Y CAPACITY 'parta NO.COMPARTMENTS s�- WO TREATMENT MM❑ DISTANCE TO NFARFIT: WELLZIL- j�T FOUNDATION� PROPERTY LINE LIFT STATION❑ SIZE TYPE OF RUMP BAND OIL SEPARATOR RENCLOSED SYSTEMI LEACMNU USE �❑y NO.a LI NDE"OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PHOMPTY UNE RITDI SED IAt W10T11 _LENGTH OEPTN_�R// DISTANCE TO NEAREST:WEuFOVNDAt10N��—PIIOPERTY LINE �C�G rPT MOMDW ❑WIDIII_LENGTH DEPTH dfTANCl TO NEAREST:WELLFOUNDATION PROPERTY NNE emAOS RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUNNI ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE WSFOSAL FONDS 13 MOTH LENGTH DEPTH OIBTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORE WILL BE DONE IN ACCORDANCE WITH SAN"AMIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JGAGUIN COUNTY.HOME OWNER ORMENSED AGENT'S SIGNATURE CERTIFIES THE FOLU)"NO:'I CERTIFYTHAT N THE PETOIMANL!OF THE WORK POR WHOH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COMPACTOR'S HINNO OR SUB-CONTRACEINO SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORM. E OF THE WORK MR WHICH THIS PERMIT le ISSUED.1 SHALL EMPLOY PERSONS WILUECT TO WORtMAN'B COMPENSATNgN/LAWS OF CALIFORNIA.- THE APPIAANT MUST CALL 24 MURS IN ADVANCE FOR ALL"BMW INSFECO TNS. COMPLETE DRAWING BELOW. ////' C SIGNED X �Nn ��/ TITLE: DATE: PLOT RAN DRAW TO SCALE)SCALE I- 1. NAMES OF"FEE-re OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISMSAL SYSTEM OR PROMISED 2. OUTUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BVIE EMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Ff.ON INCLUDING COVETED MEAS SUCH AS PATIOS,DWWWAYe,AND WALKS. TILE PROPERTY OR ADJOINING PROPERTY. JZ) w o 441- .. L � Y ' POO/— L-2 91 ✓T FICNM HFALTH HEALTH DIES - --'..'.- - �- r_ --IFiONMENTAL HEALTH DIVISIOn: FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: — AREA: _ 5 TANK,Pn OR HUMP INSPECTION B', DATE I FINAL INSPECTION BY DATE go.� ' fZeTTbD SYNo TtAt7 AEW*NAL COMMENTS e 71510, •N O ACCOUNTING OxLY: AID, E^C" PE CGDE EE INFO OUNT RFMI IIEC -ABH RECOWD BY DATE M I PERMIT NUMBRI Pub.Health Serv.-Envlro.174(3/96) 1J j. .=r ?(1''N p:1[ir'iy 7 P h SF GAVj � �" > c.r0-9 If