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APPLICATION FOR WASTE IQUI SAN'OAOUIN COUNTY L PUBLIC HEALTH S RIVILES I 1 X 1O U 7 ENVIRONMENTAL HEALTH DIVISION L V P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (209) 4883420 T 73 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED W� (Complete in Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN 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 SERVICES,ENVIRONMENTAL HEALTH DIVISION. �y r/�7[!J♦1 9's.5vo f �� ---L JOB ADORESSIOR APN/ 1.�� dU/�S t� . CITY 'C1 /n /TV I LOT SIZE_ OWNER'S NAME jr,( �-e.e o. l.P Sp ADDRESS PHONE CONTRACTORM JAC I)k-j� �<, PlUl II /Ad ADDRESS �� O .S UC/ PHONE.2o 2 f( SUB CONTRACTOR ADDRESS UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION D3" REPAIR/AODIT10N ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTNI 1 1 HOW MANY APINIo.tlon INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL OTHER ❑ NLMRFR OF UVING UNITS: NUMBER OF■EDROOMS:� NUMBEIR OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF FEET: RT/BUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIOREASE TRAP IIF3rtQTVPEIMFG :O,r L_ CAPACITY NO.COMPARTMENTS PKO TREATMENT PUNT ❑ deTANCE TO NFiFAUT: WELL�y FOUNDATION_ PROPERTY`LINE UFT STATION❑�S,IZZE TYPE OF PUMP 8AND OIL SEPARATOR(ENCLOSED SVSTEMI .Y LEACHING UIQNE F10.A LENGTH OF LINER �� _I)1 'WE/-a �pd'OFBTANCE TO NEAREST:WELL 1 71 FOUNDATION 3�PROKIRTY UNE FILTER RED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE &EVADE RTS ❑ DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME O WNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED.I$HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS�O OF CALIFORNIA.- CCALIFORRNI-,A,.- THE �APPPLLIIICCANT MUST CALL 34 HOURS IN ADVANCE FOR ALL REQUIRED;INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X �VV/�- ' , A �'iT '� TITLE: V I � " DATE:/O - I PLOT RAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREE78 OR ROADS 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 DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 14Vk4-s :�E�EIVEIJ OL (tweet �1�-(>, s y s fever no r � ' f C�6l°g�,rs v w Si v S `vo r� 3 ,FOR DEPMTMFHT USE ONLY ,\rte /�/ 1 APPLICATION ACCEPTED BV /A� LJ I�/Y y�� L/' � .V�QJ` Q DATE: `� � ✓ � 37 AREA. � • � ,/( TANK,RT OR SUMP INSPECTION BY DATE I / FINAL INSPECTION BY DATE I 0 146 lV ADDITIONAL COMMENTS: C i 1. O iLl-` rL.a ACCOUNTING ONL AIDF FACT PE CODE FEE INFO OUNT REMITTED CHECK/SCASH RECEIVED BY DATE N I PERMIT NUMBER INVOICE/ Hal 7�Sp 5o — W Y k s n c�0a—T7