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S�� APPLICATION FOR LIOUIO WASTE PERMIT JOAOUIN COUNTY PUBLIC HEALTH L, VICES ENVIRONMENTAL HEALTH DIVISION_ 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 �1 �Q �o�3 (O/V h NON•REFUNDARE PERM] EXPIRES 1 YEAR FROM DATE ISSUED �/ !! mainpintn In TFIPIMSt@l APPLICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN i JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER fl-1110.3 AND THE STANDARDS�O)F SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. � JOB ADORESBIOR APNM L/ /`t CITY 'ye/1,-�j� __LOT SIZE ll OWNER'S NAME ADDRESS_ /7-�/1��-�s'' __ PHONE CONTRACTOR /--.az ADDRESS ?ai d LICIPHONE SUBCONTRACTOR ADDRESS LICI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION D DESTRUCTION D IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.] PE RC TESTIa1 I I NOW MANY Appnmdon J' INSTALLATION WILL SERVE: RESIDENCE ISI' COMMERCIAL❑ OTHER❑ NUMBER OF UVINO UNITS:_� _ NUMBER OF SEDROOAMM � NUMBER OF EMP.OYEEB: CHARACTER OF SOIL TO A DEPTH Of 3 FEET, /11f� PIT/SUMP SOIL CHARACTER: //// WATER TABLE DEPTH fEPTIC TANK/OREABE TRAP ❑TYPE!MF0 CAPACrrY !!d �] _NO.COMPARTMENTS� , PKO TREATMENT PLANT© DISTANCE TO NEAREST: WELL--&2-0F FOUNDATKIN� PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP r9ANO OIL SEPARATOR]ENCLOSED SYSTEM) LEACHING LINE NO.A LENGTH OF LINES ! r DISTANCE TO NEAREST:WELL FOUNDATION LINE ALTER BED WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS 13 DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE $UNPs $3 WIDTH TZ /LENOT14 lG ' DEPTH DISTANCE TO NEAREST:WELL FOUNDATION_ PROPERTY UNE--,a:9- DISPOSAL PONDS Q WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES _ AND REGULATIONS OFTHE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING:'I CERTI FYT HAT IN THE PERFORMANCE OFT14EWORK FORWMCH THIS PERMIT 18 ISSUED,I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIONATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOLM IN ADVANCE FOR ALL REOUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X � �� i TFTLE:I, �-� DATE: PLOT PURI$DRAW TO SCALE]SCALE 'to 1. NAME$OF STREETS OR ROADS NEAREST TO OR SOUNDING 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 LURING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. .. .. .. ...... ........ .. .. .. _ p b :.... C �. 3...;. .. .. .. Z .. - .. .. .. .. .. RA. 2... . �1 ... a Q � 9s. .. .. PAYMENT....... ... . .. ...:. ,41C _ :...: s :...:. ENVI ONfviENfiq�HEAL7�H�V451pN ... . .... 7 Y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY • DATE:„ AREA: 1J TANK,PIT OR BUMP INSPECTION BY DATE I I _FINAL INSPECTION BY \DATE -L ADDITIONAL COMMENTS: ACCOUNTING ONLY: AI00 FACS PE CODE FEE INFO AMOUNT ROASTED ITEC !CASH RECEIVED BY DATE SRI P13- T NUMBER INVOICE S ' 9 1 ! 11sUl� Pub.Health Serv.-Enviro.174(3/96)