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APPLICATION FOR LIOUIO WASTE PERMIT !�9114 JOAQUIN COUNTY PUBLIC HE:ALTH%yPERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRDM DATE ISSUED CPN 5-01q©-a I (Complete In TTiplie*b) APPLICATION 18 HEREBY MADE TO THE BAN JOAUUIN COUNTV POR A PEPUATT TO CONSTRUCT ANDMR INSTALL THE WORK DESCRIBED. THIS AP KATION IB MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE SSTTf.A�NDA/POS/OF SAN JOAQUIN COUNTY PUBLIC HEALTH BE/PRW,,,,Ft FNVGIONMENTA HEALTH DIVISION, J JOB ADDRESB/OR AM' / 7 2. 1 V 11 ///I h ( J& CJ CITY/-1 1 A�1� LOT SIZE Lcac OWNER'9 NAME T�///t_.. �^/' I'U �V ADDRESS FIIGNE a r CONTRACTOR ./ ' /I/1 A, Alk f S Pn t. i.r /C V.AUOi�EBs IA-✓U E-/ PHONE me /5—'f�� PHONE SUB CONTRACTOR ADDRESS LICE PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION STI REPAIMADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF NBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDINGJ INSTALLATION WILL*ONE: RESIDENCE Q COMMERCIAL ❑ OTHER ❑ A-/FS'rM19, NUMBER OF LIVING UMTS: ' NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF J FEET: FIT/SUMP BOIL CHARACTER: WATER TABLE DEPTH eFDTIC iANKlU1EASF TMP ❑TYPE/MFO� �/ CARACRTV ^ L�6#IU...� NO.COMPARTMENTS PRO TREATMENT PLANT 11 DISTANCE TO NEAREST: WELL /lC'�' _r FOUNDATION PROPERTY UNE LRT STATION❑ SIZE TYPE OF NMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI f LEACHING UNE E9 NO.S LENGTH OF LINES J.- - T'(. DISTANCE TO NEAREST:WELL/- RA' FOUNDATION PROPERTY USE /l/•' FILTER BED ❑WIDTH LENOTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE - SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PNOPERTY UNE SLAPS 11 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION TNOPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE MW WILL BE DONE IN ACCORDANCE VATH SAN JOAQUIN COUNTY ORDINANCES AND STATE AWB,AND PULES (_ AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORUCENSED AOENT'B&GNATURE CERTIFIES THE FOLLOWING-ICERFIFYTHAT IN THE PERFORMANCE OF THE VAIK FORNMICH 1 THIS PERMIT IS ISSUED,1 SHAL HOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME BUWECTTO WORKMAN'8 COMPENSATION LAW*OF CAIFORHIA.- CONTRACTOR'S HIRING OR �+ SUB-CONTRACTING ISONATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO / MWMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED,INSPECTIONS. COMPETE CRAV VINO BELOW. f /- SIGNED% � ��Z-^'- TITLE: /iu�N� DATE:�X ROT PLAN(DRAW TO SCAEI SCALE_ -I- 1. NAMES OF STREETS OR WAGE NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ( l 2. OUTUNE OF THE R10PERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTUMS, S. LOCATION OF WELLS WITHIN RADIUB OF ONE HUNDRED FIFTY FT.ON (T INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. r O J _ y- .. J' PAYN9EM h . AUG 2 7 1998 POR DEPENVI�RO®Lt" AL0HSEHFAL H(DIV CE APPLICATION ACCEPTED SV DATE: AREA' TANK,RT OR BUMP INSPECTION BY DATE I / FINAL INSPECTION BV DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# F'AC4 PE COVE FEERNFO AAOUNTREMIITFD CIIECK#I BII RECEIVED BY DATE WIPERMIT NUMBER INVOICE# Pub.Health Saw -Enviro.174(3/96)