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APPLICATION FORTY P WASTE PERMIT <br /> IS <br /> SJOAQUIN COUNTY PUBLIC HEALTH SE"riVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> /1 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> \� l (209) 468-3420 <br /> yol <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> IComPltt■In TrblWtel <br /> APPLICATION IB HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. THIS APRJCATION IB MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COVNTY DEVELOPMENT TITLE,CHAPTER e-1110.3/J'D THE STA.y S OF SAy.IOAOUIN COUNTY PUBLIC HEALTH 8E ,ENVN ONMENTAL HEALTH DIVISION. <br /> JOB ADDREGGIOn AFRI C" CITY✓//y/ /JY/// Y CITY LOT SIZF d /� <br /> OWNER'*NAME A GE,�• <br /> CONTRACTOR ADDRESSPHONE <br /> LIC, <br /> / ' <br /> SUB CONTRACTOR / cc01�- t 2J <br /> RONF az 3�/3 <br /> TYPE OF DEPEND WORK: NEW INSTALLATION ❑ REPNRIADDIDDFlTRUCTIOM ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC FEWER 18 AVAILABLE WITHIN ZOO FEET OF BU NO) n PERC TESTNI I 1 HOW MANY <br /> n k APO-"..INETALUTION WILL tBiVE RESIDENCE 11 COMMERCIAL ❑ OTHER II�INw'w-�/v+ <br /> NUMBER OF(MNG UMTS:_ NUMBER OF■ OMS: H BER OF EMRO/Y'EEESS:�� / <br /> R OF 601E TOA DEPTH ODTYPEMF Pi/BUMP 601E CNCRACTEIPf�/y)7L[ /aliE. WATER TABU <br /> NOOCOMPARTMENT� <br /> SFPIP AMX/OHEA IE TRAP //p�er �'T <br /> I'M TREATMENT PLANT O DISTANCE TO MEARUT: WELL/w F FOUNDATION P OP'RTY UNE Ie-7� <br /> UFT STADON❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM( <br /> LEACHING UNE ❑ NO.A LENGTH OF LINER INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> ENTER SED ❑MDTII LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH-75 LENOTN DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SEEPAGE <br /> i <br /> tAGF PT6 ENBIZ <br /> y2_ E, ( _NUMBER J dBTNICE i0 NEAREST:WELL�OUNDATON�RbPERry UNE <br /> SUM's ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE JOAOUIN COU .HOME OWNER OR LICENSED AGENT'S SIGNATURE CESTIf1EB THE FOLLOWRNO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WUK FORW111CH y <br /> TNI D IB ISSUED, NOT EMROY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,- CONTRACTOR'S HIRING OR <br /> S {OM CT tl AT CERTIFIES THE F LLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SMALL EMROY PERSONS SUBJECT TO L <br /> RtMAN' MV All H L WB OF CAU H�APPICAMT UST CALL 24 HOURS <br /> IN ADVANCE MR AA(/�M REQUIRED INSPECTIONS. COMPLETE DRAWMO BELOW. <br /> IED X V �/' N _ TITLE: 1 - " - DATE:-cd, -H - <br /> POT RAN(DRAW TO SCAUI SCALE •1. <br /> 1, NAMES O STREETS ROAD.NEAREST TO OR BOUNDING THE POPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 1. OIITUNE OF THE POPE .WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON / <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> �/'AefcP' f2oo �l <br /> 00 <br /> eJ a o o Ls o <br /> 1 <br /> hx <br /> E <br /> fOR DEDAPTMENT USE ONLY <br /> APPLICATION ACCEPTED BY !�/V"V�A VU • ( DATE " �S�r AREA: <br /> �LUMP INSPECTION BY ///FLIM /��\ ✓�r DATE FINAL INSPECTION BY "'yr�� � / DATE <br /> ADDITIONAL COMMENIB / <br /> 1 v <br /> ACCOMEINO ONLY: AIDI FACT <br /> PE CODE FEE INFO AMOUNT NMID LIE / RMUM <br /> CASH RECEIVED BY DATE SA/PIT NUMBER INVOICE <br /> Pub.Heafth Sew -EnvirD. 174(3/96) <br />