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APPLICATION FOR LIOUIO WASTE PERMIT P (_, SAw•dOAOUIN COUNTY PUBLIC HEALTH SE-!VICES! / L tAN D U & ENVIRONMENTAL HEALTH DIVISION 007 3g 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TrlplieetMl AP'UCATION IS HEREBY RADE TO THE SAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WORK DESCRIBED. THIS AP RATION 18 MADE IN COMPLIANCE WITH BAN "AMIN COUNTY DEVELOPMENT�Ty)R-IFf}��C(H(A]��FJER 8-17/1,EOy./♦7 AND TT�HHE//$,fy �/UANENg ,�15(/�I/LJJOAWN COUNTY MOM HEALTH SERVICE ENVIIgNMEMK HEALTH pVI810N. JOB ADDRESBMJR/ATN � / `� �+/� / / /✓ ,/ /�//]��,,, �� CRY �� LOT 81"t OWNER'S NAME`-7�G aQfi� --T ADDRESS /- '♦-'�- MONE IJ�IDI CONTRACTOR ADDRESS Me RHONE Or f��1 y/E SUBCONTRACTOR L7E /F% ' AGGRESS /21I` BEPLI@ �it• IICe =+L- TYPE OF DC WORK: NEW INSTALLATION RAI INi OM OtliIIUCTNIN❑ INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF RRUIUANO.I PERC TEST01 1 l 1 HOW MIRY �(,///V��,F(/1IIAppestlan e INSTALLATION WILL SERVE RESIDENCE❑ COMMERCIAL❑ OTHER NUMBER OF UVINO AMTS:_ NURSE OF`P/ED1100Me: NII FR OF MMOY6111EII�I18: QO E))P OF SORE TO A DEPTH OF J FEET:y9i//yE� .��,�.. PRIBUeFIL CHAMCfEII: �I� YFATER TABLE UEPFH� iAN1U01EABE TIUP ❑TYPF/MFdCC- H:. ' tA,.♦Q CMACRY I, NO.COMPARFMEM6 MO TREATMENT PANT❑ DISTANCE TO NEAREST: WELL � FOUNDATION-� I PROPERTY Unnk: / LRT STATION❑ WE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACHING LINE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNOATION PROPERTY LINE FILTER BED ❑WROTH LENOTN DEPTH DISTANCE TO NEAREeY:WELL FOUNDATION PROPERTY UNE MOUNDED �E❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PRUPERTY UNE SEVAOE PTS ,EIPEPFH cT S ' WE NUMBER DISFANCE TO NEARBY:WELT i�.�MLMATMIN /0 , PEOPEMY UNF 4} / SUMPS /❑WIDTH LENGTH DEPrt DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE WMFOMAL FONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOLINOATgN PROPERTY UNE — I HEMSY CERTIFY THAT 1 HAVE PREP D THM APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAWIN COUNTY ORDINANCES AND STATE LAWS.AND RULES ANUROULATIONSOFTHESMJOA IN COVNTY.NOM FOWMROAMENSEDAOEM'B BIONATVRE CERTNIESTHEWLLOWINO:'ILEMIFV THAT IN THE PERFORMANCE OF THE WORK FORWNION TMB PEPAR ISSUED.I S11AL NOT MPEOY ANY PERSON m 811CH A MANNER AB TO BECOME SUBJECT TO WORKMAN'S COMRNSATION"We OF CALIFORNIA.- CONTRACTOR'S HIRINO OR NO NATURE DEMI IFS THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE NOFZ FOR WHION TRS PPMR IB IBBVED.I SHALL EMPLOY Pfl80N8 SUBJECT TO NJDRLM C i` S H1H UWB C FORM THE APPICANT MUST CALL It HOURS IN ADVANCE FOR ALL REOURED INSRCDONe. COMPETE OMVANO BELOW. EI , S��r-1�C TIT ��~- DATE: KORO% PLOT PLAN"W M SCALE,SCALE_ lu 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DIBWBA SYSTEM OR PROPOSED 2. OUTIINE OF THE PgPERW,WITH DIMENSIONS AND NORTH DIRECTION. E%PMBION OF$MADE DREW SA SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EMOTING AND PROPOSED STRUCTURES. G. LOCATION OF WELLS MTHIN RADIUS OF ONE HUNDRED FIFTY FT.ON ONCLODING COVERED MEAS SMV AS PATIOS,Ofl! WAYEI.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. ( n fl v 1 1I JU $ ,Opp Ngf,\ pN1$\ON�r � i 1 1 {Yb'\d 3 " Lro, zJ 0 f x K ' �♦� A ' Pw � (7 nl�S �. A Ytp l{M Irr , \ � u• (1 1 I77 �•K TJ/ V\ IPJ^ V\ 1 ' ♦ 1 _ . wr .r w - � , • ♦ L T I ♦ �, r L 1 A ^ �^ AFORE MTMENT USE ONLY APPLICATION ACCEPTED BY llt/YR/�A♦rw`LY�TJJi` /�(,`•L /� DATE' • {- I ` �C A11EA: 21 I 1 P OR BUMP INSKCTIO14 B�VT.L G. e�o a DATE? I FINAL INSPECTION BY DATE ADCITIONA1CFOOMMEMe: \ 1�•�+' ` I�M�wW U' T AecolmnnG ONLY: Ave RAts Wrat- � NFO AMOUNTR@AIITED (CASH PE RVFD SY DATE MIPRMYBT NUABRL INVOICE/ 5Z� 5L is7s Tai f� PJb.Heafth Sere.-Ewsro.174(3/96)