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APPLICATION FOR 1.1111.110 WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ,� 4 <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 \ ��\f <br /> (209)468-3420 \ <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Trpliaatel <br /> APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATRIN IS MADE IN COMPLIANCE WITH BAN <br /> .OAOUIN COUNTY DEVELOPMENT 1rtlF.CHAPTER B-11(1O.J AND E ST APDB OF BAN JOAOUIN COUNTY FIRIM HEALTH SERVICES.EN,V/I(RONMEMAL HEALTH DIVISION. <br /> JOB AODRESG/OR AFNNIE x,40 ff�,'E\ 1 / 'U"�' CITY k t✓Ido" LOT <br /> 02,2Ar <br /> OWNER'S NAME 244- <br /> CONTRACTOR <br /> N H ./ `PFKINE�.J d/ <br /> CONTRACTOR /7 h ITJI�i C7/F' S • ADDRESS lJ% 7 F-Z'Z:• IAC!T 71 `I R10NE��I��VT I <br /> SUB CONTRACTOR ADDRESS IlC1 PHONE <br /> TYPE OF SEPTIC WORK: MFW INSTALLATION ❑ REFAMIADO1T10N DESTRUCTION ❑ <br /> INO SEPTIC SYSTEM PERMITTED O FtMM SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PLTO TNTM I 1 HOW MANY <br /> AppYstl°n I <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER 11 <br /> NUMBER OF"NO UMTS:( NUMBER OF SEDROOMS: -� NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OF O FEET: FR/SUMP BOIL CHARACTER: J WATER TABLE DEPTH <br /> _ SE111C TANK/ONEASE TRAP ❑TYPFMF(1 h L-O N,C�i`NTf' CAPACITY /L DC3 NO.COMPARTMENTS -+L <br /> PRO TREATMENT NANT❑ DISTANCE TO NFMFBT: WELL /D d T FOUNDATION 7 <br /> O FPAFERTY LINE .26 ' <br /> LIFT STATION❑ SIZE TYPE OF PUMP_SAND OIL SEPARATOR(ENCLOSED SYSTEMI <br /> LEACHING UNE ❑ NO.a LENGTH OF LINES /'-�sLl .t 11� DISTANCE TO NEAREST:WELL_/rine FOUNDATION PRO(ERIY LINE <br /> FILTER BED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> MOUNDED ❑W)DTN LENGTH DEPTH { DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SFEPAOE FITS ❑DEPTH '1 S i BEE '1(: A, NUMBER F DISTANCE TO NEAREST:WELL / SC)}FOUNDATN)N 10 PMPERTY UNE Z� <br /> BUMPS ❑WIDTH LENGTH DEPTH DIBTANCETO NEM ":WELLFOUNDATM N PIOPERf ME <br /> DISPOSAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS ARUCATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND WOULATONa OFTHE SAN JOAOUN CCLRITY.HOME OWNER ORLICENSM AOEHT'S SIGNATURE CERTIFIES THE FOLLOWING:')CERTIFYTHAT LATHE PERFORMANCE OFTHE WORK FOR WHICH <br /> THIS PERWT M ISSUED,1 SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO SECOME BUBIECT TO WORKMAN'S COMPENSATION UWB OF CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> SUB-CONWACT1N0 mONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE FERMAMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED I SHALL EMPTOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORMA.- THE,AFPUCAXT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> BONED% it s - / TITLE: ! EI lY +1091 C64 OY DATE:/ O <br /> ROT PLAN(DRAW TO SCALE; <br /> 1, NAMES OF STREETS OR MADS NEAREST TO OR BOUNCING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMSED <br /> 2. OUTUNE OF THE RDPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DHIPOSAL SYSTEMS. <br /> 0. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED MEAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR AD"I ING PROEERTI'. <br /> A <br /> T " <br /> lr PL <br /> N�:LBiI � 2 <br /> on ryryryry <br />