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APPLICATION FOR LIOUIO WASTE PERMIT 'bW*'JDADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX SOB, 904 EAST WEBER AVENUE, STOCKTON, CA 95201388 U� (209( 468-3420 NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in THplleste) APPLICATION Ie HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PEANUT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APRJCATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11110.3 AND THE STAN DB F BAN(/JpAOVIN COUNTY PUBLIC HEALTH BER CES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDREBB/O/RyA�.[PN11 :IJ��(�}�.� C.. YJ��Lt r'L ( /I\ti� CITY ' . owNER'S NAME_Y )'�I - {,� ��E'4 1,�.N I_ j /SLOT 82E��/�'LJC f ADDRESS 14'C 7 F. �t(. 1 LE � C- PHONE 76(1'177 S•• cONTnACTOR_��'Lc'7(>'as S t ADOPER6/2/ f. alt wY�� .{S`f Si�Lc LID, z1S` PHONE�&L 5 �3 SUR CONT11ACIOn ADDRESS IIOI PHONE TYPE OF SEPTIC WORK NEW INSTALLATION ❑ REPAIdADDITION DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IB AVAILABLE WITIIIN 2D0 FEET OF WJLDINGJ PEIP TF1TtFl 1 1 NOW MANY AppBEetlen, INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF 601E TO A DEPTH OF O FEET:lwe44 PRISUMP BOR CHARACTER, WATER TASTE DEPTH -70 ~ 6FPTTC TANKIORFASE TRAP ❑TYPEJIAFG CAPACITY--�-- NO.COMPARTMENTS PRO TREATMENT PLANT ❑ DISTANCE TO NFAAUT: WELL FOUNDATION PROPERTY'LINE [Q� UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR IENCLOBED SYSTEMI LVA LFACUING UNE NO.a LENGTH OF LNEBO�S - Z Lt e, 01-K' a /r- DISTANCE TO NEAREST:WEIC`1Z1 Y IA FOUNDATION /0 PROPERTY LINE 3C 11 I FILTER RED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPT" DISTANCE TO NEAREST:WELL FOUNDATION PIROPEMV UNE L� SEEPAGE RTS )abEPTH�_SIZE E /• NUMBEq�_DISTANCE TO NEAREST:WELLL� FOUNDATIONS rmnE UNE } (- 6UMP4 ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION P"GPERTY LINE dSPOSAI PONOS ❑WIOTN IENOTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY IINE O 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES'Q- AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFYTHAT IN THE PERFORMANCE OF THE MW rOR W111CH THIS PERMIT IS ISSUED,1 SHALL NOT EMMOY ANY PERSON IN SUCH ANNE"AS TO BECOME SUBJECT TO WOIRMAMS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING on ` SUR-COM TINA SIGNATURE CIETH F.B THE FOLLOWING: 9 CEM( (IAT IN THE PERFORMANCE OF THE WOIK FOR WHICH TNI!PEIIMIT IS ISSUED.1 SHALL EMPLOY PERSONS BIIRJF.CT TO WOPIM C.7 C PENS UWS CALIFORNIA.' THE APPUC T WT CALL 31 HOImS TM ADVANCE FOA AlL REGURFD INSKCTIONS. COMRFTE DRAWING BELOW. 1> m SmNFD% _\ TITLE J PLOT RAN(DRAW TO SCALEI SCALE 'm I. NAMES OF ST"EETS OR"CADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMSEO 2, OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SFWAOE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT ON INCLUDING COVERED AREAS SUCH AS PATIOS,ORIVEWAYS,AND WALKS. /J THE PROPERTY OR ADJOINING PROPERTY. / ( i QT t5 _0 f✓ � n.6 �-� ALL,': �h� i, L,I�,„, �',.�I,� Plf OCT e 3 1997 FOR DEPARTMENT USE ONLY SAN JOAQUIN COLINIY PUBLIC HEALTH SERVICE,. APRICATTION ACCEPTED By �U Ln�i DATE: CNMENTA�,�LTH LSI N ry TANK,/ST' R SYMP INRFECTION BY rj- ( (�jl. �T r �If DATE I U 1 i0 J 9 1 FINAL INSPECTION BYXajvu-tDATE ADIBI TONAL COMMENTS: ACCOUNTING ONLY: MD, FAC, PE Cone FEE INFO AMOUNT REMITTED CRECwJCASH RECRVED BY DATE SR r PERMIT NUMBER INVOICE