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�t } APPLICATION FOR LIOU10 WASTE PERMIT " �. BAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES E f ENVIRONMENTAL HEALTH DIVISION PA.BOX 988,$04 EAST.NfEBER AVENUB,-.STOCKTON,CA 9..201 388 (2091 488J42O ROM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compl6q in TrlplioBLB) APRJCATION IB HEREBY MADE TO THE SAN JOAWIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCAIRED.THIS APPLICATION IB MADE IN CPMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENTTRUE,CHAPTER 9-111 D.3 AND THE /STANDARDS OF SAN JOA WIN COUNTY PUBLIC HEALTH//SERVICEES�,ENMRONMENTAL HEALTH DIVISION. 1 G:✓l.'..0Q"✓: K� CITY L� -L- LOT JOB apDREssroR ATNF I 9 5.2 ,_. OWNER'S NAME ADDRE88_—91 -.�� ,y-0-'i VO C4- -A-we-4,, ____ PHONE J.27/61 CONTRACTORV7 To/�_�� 'L ADDRESS iZ!C. Cf LIA'LC �-,G� 3�. LIC/G Z- _ ��PHONED SUR CONTRACTOR ADDRESS UCS' PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ RE/AIRfAQQITIO QFSTIIUCTION❑ �R IND SEPTIC SYSTEM PERMHTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BVILIJING.I PBiC TEOTI.I 1 3 HOW MANY I. A-4-6../ INATALLATION WILL SERVE: RE;IDENC OMMERCIAL❑ OTHER❑ Il' li NUM9M0 4NNO"NITS:^Z 14A 1ROFBEDROOM6: NUMBER OF BNPLpYFEi: CHARACTER OF SOIL TO A DEPTH OFTI---31 FEET: PITISUMP SOIL CHARACTER: ('I,r•�.-�¢.0 hU WATER TABLE DEPTH SEM.TANAIOREAFE TRAP El TYPE IMFG CAPACIw NO.COMPARTMENTS PRO TREATMENT PLANT❑ DISTANCE TO NEAREST! WELLFOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP I� SAND OIL SEPARATOR(ENCLOSED I YBTEMI j LEACHING LINE �NO.i LEN[ITH OF ONES 1� 7 p` /i.��DISTANCE TO NEAREST:WELL L�+'Y FOUNDATION- PROPERTY UNE FILTER DFD ❑WROTH LrNOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑`WIDTH LENGTH +9 DEPTH �L DISTANCE TO NEAREST!WELL FOUNDATION fROPERIY UHE r ■FFAAOE RT{ jxv.?H�I SME 'J�'rU NUMBER P1 DISTANCE TO NEAREST;WELL:O FOUNDATION C-d PROFERTy UNE�_V T C. 3 j SUMPS (❑WROTH LENO7H DEPTH DISTANCE TO NEAREST.WELL FOUNDATION PROPERTY UNE l II �(! I DISPOSAL PpNp6 11 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE L I HEREBY CFRTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOVIN COUNTY ORDINANCES AND STATE LAWS.AND RULE; n ANDREGUUTIONSOFTHERANJOAOUINCOUNrY.HOME OWNER OR LICENSED AGEW';;IOHATURECEIRIFIEBTHEFOLLOWWO:'ICEFMrYTHATINTHEPERTORMANCEDFTHEWOWF*hW CH THIS PERMIT 18156UED,i SHALL NOT EM RSON M SUCH A MANN AB TO BECOME SUBJECT TO WORKMAN';COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR sUB.CONTRAC A EMIT)B THE FOLLO NO;9 CERTIFY TH 1 THE PERFORMANCE OF THE WORK FOR WHICH TRIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO [[ILII WORKMAN' OMPEN6 1 B AUFORNIA.-THEA T ALL K HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPLETE DRAWING BELOW. SIONE6 X TITLE: DATE: .y �^ \\ PLAT PLAN ID11AW TO SCALER SCALE ! I 1,NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. •ISS. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM GR HgPDsEn 4 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STIIUCTUREB, 6,LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVEREDAREAS SUCH AS PATIOS,DRIVEWAY;,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. r-. 1:0o 7 e,w° ' ....i. .... .... ..,,, .ILLI, ....t...... ' I '. .. I E . .., _ tonv n II - - - -- iJWL G H-AL N t>! lLNtT L l.rtA..L FOR DEPARTMENT USE ONLY /� �•� APPLICATION ACCEPTED BY PATE: AREA: ) + 'µ' TANK,&AA SUMP INSPECTION 6Y DATE .ry NAL INSPECTIONS 1Ir AUDMONAL COMMENTS; !I ACCOUNTING ONLY: AID# FAC! - PE CODE AMOUNT REAM TTED HEM AICASH nyr.Ervyp ey DATE AS f P 'T NUMSM INVOICE A 111' ! 0 7 z fl