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APPLICC"N FOR LIOUIO WASTE PERMIT SAN JOAO ,OUNTY PUBLIC HEALTH SERVICES E:Nb,..JNMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATR ISSUED {Complets In TTipl'NxtPI APPLICATION IB HEREBY MADE TO THE SAN JDAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AMOMA INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAWN COUNTY DEVELOPMENT TITLE.CHAPTER 9-t 110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLK:HEALTH SERVIctS.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSlDR APHO 'F-� Q^ �r /",•I� M./ r n CITY 6001 __.._ __LOT SIZE OWNFR'S NAME U(4l 1 E/1�/.y X40/ W'�r A ��1 ADDRESS O PHONE -I..( �'73� of Ou CONTRACTOR //(.1 �,�1+A"1 _�1.Ir rr•T`-fiI ./jv-ADbRE96 �Z �� !Ip2- UC# R10NE��0 f3 +•- /T"S!„'F CVIW�L-1 4LLADDRESS � 5116 CONTRACTOR LIC+ PHONE 1 TYPE Of dEP'TIC WORK: NEW INSTALLATION REPAIIVADg770N❑ DESTRUCTION❑ SND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF SURDIND.) —TESTI-I I I HOW MANY AmA-1SS S INSTALLATION WILL!RINE: RESIDENCE❑ COMMERCIAL OTHER❑ NUMBER OF UVING UNITS: NUMBER OF DEDDRROOMS: NUMBER OF E MA DYEEB: CHARACTER OF�f oA OEPTH OF FFEEEP�QI y PI7ISUWP SOIL CHARACTER: WATER TABLE DEPTH�� j F NS FSI P 4E Cyt' AFAcrry 3 Q C>U G AL NO.COMPARTMENTS[� PRO TREATMENT PLANT❑ DISTANCE TO NEAREST: OU {�uWELL rT— FNDAnON IIO I L L1' PP6RY UNE LIFT STATION Q SIZE TYPE OF PGM#QLOIL SEPARATOR IENCLOSED SYSTEM) LEACHNO LINE 0 ND.i LENGTH OF LINES _. C'r_DISTANCE TO..ST:WELL FOVINbATION PROPERTY UNE /,I��47— RLTF1tBED ❑WIDTH OD f-LENOTN'"I 7Q FI DEPTH G�feDISTANCE TO--I:WELL1 JVD f'1 FOVNDAMNO /2u""PROPERTY HNE—Ljj-� MOUNDED 0I-y WIDTH LLNGtH U DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY NE SEEPAGE RTS L.J DEPTH DQE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UW SUMPS ❑vmmi LENGTH DEPTH OISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS 0 WIDTH LENGTH OLPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE — I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WKL BE DONE IN ACCORDANCE NTTH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAO"COUNTY.HOME OWNER OR LICENSED AOENT'S SMNATURE CERTIFIES THE POLLONIINO:I CERTIFYTHAT INTM PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB TBSUM,1 SHALL NOT EMPAY ANY PERSON IN OWN A MANNER AS TO BECOME SVSJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORGA.-CONTRACTOR'S HIRRNO OR SUB-CONTPACTING BIDNAT SITS THE " RTIM THAT M THE PERTORAANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT 70 WORKMAN'S COMPEHB OF C ANT MUST CALL 24 HOURS IM ADVANCE FOR ALL REOURED INSPECTIONS.COMPLETE DRAWING BELOW. SIGNED X / _TITLE:/ • DATE: V 111 ROT PLAN(DRAW TO SCALE)SCALE -In I T.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDWO THE PROPERTY. 4,LOCATION OF HOUSE RLWAGE DISPOSAL SYSTEM OR PRDP06ED V 2.OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.3.OIMENBIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6.LOCATION OF WELLS WITHIN PAWS OF ONE HUNDRED PIP"FT.ON INCLUDING COVERED AREA"SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ALIJOMrW PROPERTY' .....:......:... .c.... :... ..... _ ..:... ... _....!_ .i..... ..... ..... ... ;. .. .....o.... .... i-- .... ..1 ...., .... ....a .... .. i... _......o... _ .... ..... . ,.. ... . .. .: .. C ... :. ........... .. ....... : ... .....4 ... ... . _. ... AT �... ... :. . 4 :5. .. � ... ....... ...... :... ,. ;. 3NTN J`J:,,fiJSkf.LL�LA I.T . .�. ... _. " p iE[+IVIfiQNMLiNTAL HEALTH IO DIVISN `. I \ �/ / / F TMEMT kISS ONLY I APPLICATION ACCEPTED GY � /d'SC �/f/ DA7E:11/ -�N / -- _AREA: TANK,PT OR SUMP F NSPECTIO14 BY DATE 1_..I _FINA- n)BYf i-n) � �� DATE U ADDITIONAL COMMEMs: -1 ACCOUNnrm ONLY: AIOS FACF PECODrEE� FEEINFO AMOUNT SVA%TFO )NEC ICASH RFC O BY DATE SR I FEM T NIBMBEI INVOICE---;F NVOICE/ Pub.Health Sam•En*O.174(3/96)