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APPLICATION FOR LIOUIO WASTE PERMIT ';nN'JOAQUIN COUNTY PUBLIC HEALTH SERVICI z ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388. 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CBmPIBt, In TriPDBBtBI APPLICATION IB HEREBY MADE TO THE BAN MAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SE,RVICES,EN//VIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APNI 1 -7 -700 F. L; b g.4y TZXC[ crry t"J-e �Q.n9!5-()3'7 1�5A� LOT SIZE6AAaL . OWNER'S NAME ( D1 ADDRE881 T G] NAPL501t L-�I Ytl,L64^5, 7�W 7 PHONE. Q/ '-7'I& y CONTRACTOR S-�r4L ADDRESS/Z/ tGA'B E#wtAl.(I � S7#�c UCS Z rPHONE_ ( `S JqJ SUB CONTRACTOR ADDRESS IICI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPRR/ADDITIO DUMMMON ❑ INC SEPTIC SYSTEM PRMITTED IF PYBUC SEWER IS AVAIUBLE WITHIN 200 FEET C UILDINO.I FmIC TSSTI#I 1 1 NOW MANY APPSSNen I INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL 13OTHER ❑ NUMBER OF UMNO UMTS:/ NUMBER OF BEDROOMS:I_ NUMBER OF EMPLOYEES: CH R OF SOIL TO A DEPTH OF 3 FEET:ZZ�3�a iSL�A,- Prt78UMP SOIL C�HLAiRAAC R WATER TABLE DEPTH SE/TIc tANR/OIIFASF TRAP ❑TYPE/IAFG( �tt�•C. "4 K- WAC 2-&C�' 4 A( NO.COMPARTMENTS L O C'"`P lFNT RANT❑ DISTANCE TO NEAREST: WELL(5 eE9 \/- FOUNOA— T�� PROPERTY LINE 160''f UFT STATION❑LLLLLL.....8...rrrryy12Z�E TYPE OF RUMP BAND OIL SEPARATOR(ENCLOSED SME�MIn...w LEACHING UNE ANO.►LENGTH OF LINES I_e(d �-`� DISTANCE TO NEAREST:WEU.2e5'LIF FOUNDATION 5'0 PROPEIT/LINE / /+ RLTFIR BOD //O WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE r MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE T SEEPAGE RTS DEPTH Z. 812E '3 Lo E NUMBER DISTANCE TO NEAREST:WELL cQLl FOUNDATIONCJ PROPERTY LINE / Own ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE _ mSPOSAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE /Vl I HEBEBY CERTIFY THAT I HAVE PREPARED TWO APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND MOULKTIONS OF THE BAN JOAQUIN COUNTY.HOMEOWNER OR ENBED AGENT'S SIGNATURE C ERTIFIES THE FOLLOWNG:'I CERTIFY THAT IN THE PEPIFORMANC E OF THE WORK FOR WHICH TMS T 10I ED,1 SHALL NOT PERSON IN SUCH ANNER AB TO BECOME SUBJECT TO WOR(MAN'B COMPENSATION UWB OF CAUFOPMA.' CONTRACTOR'S HIRING OR BY OMFACTINO 1 UR C OFlE HE MOWING:'1 CERT AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I BNALL EMPLOY fSR80N8 SUBJECT TO RRMAN'8 CO. TION .LIFO IA.' APFV NT M ST CALL 24 ROUIU IN ADVANCE MR AM R[Gtm1ED INSF[CTONB. COMPLETE DRAWING BELOW. OWEDX I - TITLE: \ A'dit4tC� DATE:-,;--lal- ((a \� ROT PLAN(DRAW TO SCALES SCALE 'to 1. NAMES OF STREETSORM 'NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY',WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIOMBAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVETED MEAS SUCH AS PATIOS,DRIVEWAYS,AND WALK8. THE PROPERTY OR ADJOINING PROPERTY. 77.7 �3k" �> >' ,, l wVile {/ r I , MAY I'v quN k4 NY Lit FOR DEPARTMENT USE ONLY p APPLICATION ACCEPTED BY DATE: L AREA: TANl�OR SUMP INSPECTION BY DATE. FINAL INSPECTION BV ATlTT.S�S CCCCCC///// y ADDITIONAL COMMENTS: ACCOUNTING OH Y: AID# PAC# PECODE F AMOUNT REMITTED NECK GASH RECEIVED BY DATE All/PERMIT NUMBER INVOICE# '\ jtll 0P7ou