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APPLICATION FOR UOUID WASTE PERMIT <br /> - SAITJOAQUIN COUNTY PUBLIC HEALTH SERVICES y <br /> n <br /> ENVIRONMENTAL HEALTH DIVISION 0' (Q <br /> <� 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> t (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmpIEb M Triplicate) <br /> A ATION IS HERESY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APRICATRIH IB MADE IN COMPIANCE WITH BAN`_ . <br /> JOAWm COUNTY DEVELOPMENT TITLE.CH 0.111 A1A�STA�AroB O� JOAO�CO RIBUCCN�TN ERq VICES.ENVIIONMEMAL HEALTH Y OT SNE�OILA <br /> JOB ADDiESSIOR AAS/PNI/� /`''lryF /`,'�,lT�/�)^�/ 4 1-+ �� (� ///yam/�•�,'_"" <br /> OWNE11'S NNAE�\,�1J�pr1�,y-y'-�Y Q,1 A.l�\ -T ADDRESS [r�T1'v-o-- (� PHONE <br /> - CONTRACTOR s�v`DG?/T0.�1' %�� • ADDRESS IZ-I C - C�++T'� NC/ 22J 'm., <br /> SUBCONTRACTOR ADDRESS UL/ PONE <br /> - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIMAONTION• DFATRUCTION ❑ <br /> IND SEPTIC SYSTEM KRMIITED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) FERC TESTIH I 1 HOW MANY <br /> App6wtlen/ <br /> INSTALLATION WILL SERVE: RE DENCE yI/ COMMERCIAL ❑ OTHER❑ <br /> NUMBER OF LIVING <br /> XUM <br /> BER OF EMKOYEEII: <br /> CHARACTER OF SON. O A DEPTH 3 FEFIIe6I G ' PIT/SUMP SOIL CHARACTER:e/4 V4 WATER TABLE DEPTH <br /> SEPTIC TANK/GREASE TRAP ❑ME/MF CAPACITY NO.COMPAArMEM6 <br /> WO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> LIFT STATION❑ SS12E TYPE OF PUMP <br /> /� SAND OIL SEPARATOR IENCLOSEO SYSTEM) <br /> �-p) <br /> LEACHING UNE FII NO.S LENGTH OF LINES A Y0, �I eix D YTANCE TO NEAREST:WELL FOUNDATION FOUNDATION �Q I PROPERTY NNE l 00 ' <br /> FILTER BED /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION FROPERTV UNE <br /> MOUNDED 1�❑y WIDTH LENGTH DEPTH DISTANCE TO NEARIU:WELLFOUNDATION PROPERTY UNE <br /> SEEPAGE NTS )..J DEFT" O;'I SE SIZE 3(Cl" NUMBER DISTANCE TO NEAREST:WELL /C'O' FOUNDATION /0 PROPEUN <br /> RTY E <br /> SUM% ❑WIOTN LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY ME <br /> DISPOSAL IONDS ❑WIDTH LFNOTN DEFTH DISTANCE TO NEAREST:WELL FOUNDATION PORERTY LINE <br /> - <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE"K WILL SE DONE IN ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AIA) TONS OF THE 9/JN JOAGUWC .HOMEOWNER OR UCENSEDAOEM'B SIGNATURE CERTIFIESTNE fOLLOWIND:•ICERTIFVTHATNTHEP:E MANCEOFTHEMWMRVINICH <br /> TIB <br /> B IB ISSUED,1 SH T p1R0 PERSON D SUCH A MANNER AS TO BECOME SUBJECT TO NOIKMAN'B COMPENSATION UWS OF CAUTOINIA.• COMRACTOR'S NIWNG OR <br /> - BV OM IPO NA C RTES FOLLOVJINO:T CERTIFY THAT IN THE RE16ORAANCE OF THE WOR(FOR WHICH THIS RERMIT IB IBBIJED.I SHALL EMTLOY PERSONS SUBJECT TO <br /> WO MAN'S C MPEM U OFC RMA.• THE AP%1CANT MUST CALL 2A IDUIIS IN ADVANCE FOR ALL REOURED IN6RECTOHS. COMRETE DIUYIINO BELOW. <br /> C C <br /> x <br /> ROT PAH mRAw TO SCALE)SCALE_ •to <br /> 1. NAMES OF STREETS ON ROADS NEAREST TO OR SOUNINNO THE PHOPERTY. 4. LOCATION OF HOUSE SEWAGE wNOSAL SYSTEM OR PROPOSED <br /> 2. OUNRNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> '- SKLUDING COVERED AREAS SUCH AS PATIOS,DRVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> 3fc"X2SI '�.+5_. �' 1 <br /> .gid' 1 <br /> O ; <br /> y\ <br /> .. 1 <br /> nEGEwED <br /> .. ' DEC olaw <br />