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Alv. ATION FOR LIa1110 WASTE PERMIT .i SAN JOAVUIN COUNTY PUBLIC HEALTH SERV) ENVIRONMENTAL TIC HEALTH DIVISION iL 304 EAST WEBER AVENUE, STOCKTON, CA 55202 1 :j (209)466-3420 q q 1-44 PERM) EXPIRES 1 rEAA FROM DATE ISSUED / (Compldh In Triplieitsl S APPLIC APPLICATION COUNTY HEREBY O D ET THE N JOA RU9-1110.3 AND THE PERMIT TSTANDCO OF SAN JOAOUIRUCT N CO NTY PUBLIC HEALTH ERVICES,ANVMR INSTALL THE WORK DESCRIBED. IENVIRONMENTAL HEALTH DIVISION-ION 18 MADE IN COMPLIANCE WITH SAN JOAQU LOT SIZE 2 JOB ADDRESSIOR APNE V O77 6 W - • '. PH 4 OWNEWSNANIE 1.IC1E r"d `~� _ADDRESS 1 UCIF,PHONE ADDRESS CONTRACTOR LICe ,PHONE�,_�� I SUB CONTRACTOR ADDRESS REPAIIVADDITION ❑ DESTRUCTION❑ TYPE OF 6EPTIC WORK: NEW INSTALLATION I PFJRC TESTb)L 1 HOW MANY INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER ISA LABLE WITHIN 200 FEET OF SUI DINO.i Ap�mdon i OTHER❑ INSTALLATION WILL SERVE. RE8IDENCf% COMM£RCFAL❑ I NUMBER Of.BEDROOMS!—NUMBER OF EMPLOYEES: NUMBER OF 11VIHG UNITS: WATER TABLE DEPTH CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PTTIBUMP SOIL CHARACTER:_, �� CAPACfi'Y HO.COMPARTMENT$ SEPTIC TANK/OREASE TRAP PROPERTY UNE_�� PItO TREATMENT PLANT❑ ddTANCE TO NEAREST: WELL_ FOUNDATION LIFT STATION❑ SIZE_TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYBTfMI 019TANCE TO NEAREST'.WELL FOUNDATION PROPERTY UNE a LEACHING LINE ❑ NO.6 LENGTH OF LINES PROPERTY UNE LENGTH DEPTH DISTANCE TO NEAREST'.WELL_FOUNDATION .�— FILTER BED ❑WIDTH PROPERTY LINE LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION — MOUNDED ❑1MDTH PROPERTY LINE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION , } SEEPAGE ATS ❑DEPTN_ SIZE FOUNDATION PROPERTY LINE SAPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LIN£ _ DISPOSAL PONDS 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL— AOUIN COUNTY 0!;ZiiiiZ�� ES AND STATE LAWS,AND RULES I HEREBY CERTIFY THAT f HAVE AND REGULATIONS 0FTH BAN.,p OUINCOUNTYAPHOMEIOWNERORLICENBEDAOENT8816NATUN AND THAT THE WORK WILL BE NRECERTFE ATHEPOLLOWINO:'1CFFMFYTHATINTHEEPERFORMANCEOFT14EWOFM FORWH1CH j THIS PERMIT IS 18SUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME BUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTIUCTPR'8 HlfprM O I WORKMAN'S CTIIMPENSATION LAWS OF CALIFORNIA.'NTHE •1/1APLICANT MUST CALL 2 HOURS N CERTIFY THAT IN THE ADVANCE FOR All REDUIRED NOF THE WORI(Fop WHWH IBPECTIONa.S PERMIT 18(COMPLETE DRAWINSSUED,I SHALL G BELOW PERSONS SUBJECT TO 4. ✓ TITLE: SIGNED - PLOT FLAN(DRAW TO SCALE)SCALE 'Ie� �, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED S. NAMES OF STREETS OR ROADS NEAREST TO bR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEM8. 2. OUTLINE OF THE PROPERTY,WrTH DIMENSIONS AND NORTH DIRECTION. 6, LOCATION OF WELLS WTWIN RADIUS OF ONE HUNDRED FIFTY FT.ON 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, THE PROPERTY OR ADJOINING PROPERTY. INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS..,... 7777777 _ .. r�--«M-- - - .�' .,M, AFVaL S a ImLM --. I IL ....,.- .......... ...... :. yam, .. .... .. PARCEL I E a aOe a es $ Ei'. 4 � - .:.......:.......:......:OOT-07�i0 I�8S.6. pg ` ..... ...:.... R . ....., ,....-.: . fl 56F[R7 I OOT-iOO-IO ..... . - .... .... ...E... . �! _........:.....E PARCEL E i. .... ..Q.. ... __ .,: :I 40sA ncs A-` O Ir FOR DEPARTMENT USE ONLY I{` —�•�� ENVIRON^�1ely-�A'� •-'- ,� _ DATE: 1 1 � ._AREA:�� APPLICATION ACCEPTED BY J TANK,PIT OR SUMP INSPECTION BY DATE fINAL!N$PECTION BY DATE ADDITIONAL COMMENTS: L ACCOUNTINO ONLY: AID/ FACT FEE INFO AMOUNT REMIRTEG CHECKNIC H REC13VED BY DATE SR/PEIV AT RUMBER INVOICE PEcDQ 0c 1 I� I I { Pub.Health Serv.-EnvirG.174(3/96)