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APPLICATION FOR LIOUIO WASTE PERMIT <br /> S7XN JOAQUIN COUNTY PUBLIC HEALTH stRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> 1110N REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplitete) <br /> APPLICATION IB HEREBY MADE TO THE BN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT NDNR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH MN <br /> "AMIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE MNDARDS OF SN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> b� .a^„✓1(]� LOT NZE� <br /> JOB ADDREBBroR AM' PHONE <br /> -� cRY "��� ^ �� <br /> OWNER'S NAME Q ” . L\Y.'J Jn ADDRESS <br /> COMRACTOR <br /> ADOPEss \T1 �ily. ..n ,bLxe Ac�Ta1 _PIONE -lZ"��i493 <br /> SUB CONTRACTOR <br /> ADDRESS tic, PHONE <br /> TYPE OF SEPTIC WORN: MEW INSTALLATION ❑ RE AJFUADOIT10N CZ- DESTRUCTION❑ <br /> TFSTIN 1 I HOW MANY <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.( <br /> RIC <br /> MFBFSeen <br /> INSTALLATION WILL SEINE: RESIDENCE M COMMERCIAL❑ OTHER ❑ <br /> NUMBER OF LIVING UMTS:_ NUMBER OF BEDROOMS: 3 NMMBER OF EMPLO/Y�EESS; / <br /> 1, pTNSUMP SOIL CHARACTERa - v1, WATER TABLE DEPTH--�L_&2 I <br /> CHARACTER OF 401L TO A DEPTH OF J FEET: _ YL <br /> SFTIC TNK/d1FASE TMP ❑TYPEn.IfG <br /> CAPACITY NO.COMPARfMEMTB <br /> PNO TREATMENT PANT❑ DISTANCE TO NEAREST: WELL <br /> FOUNDATION PROPERTY UNE <br /> UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) <br /> LEACHING UNE ❑ NO.S LENGTH OF LINES <br /> DISTANCE TO NEAREST:WELL FOUNDATION IOPERTYUNE <br /> WOPERTV LINE <br /> RLEND PILTEI BED ❑WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST:WELLFOUNDATION <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:MU_FOUNDATION- <br /> qqyy�� FOUNDATION PROPLRTY UNE <br /> SEEPAGE PTS f$DEPTH. SIZEIL NUMBER DISTANCE TO NEAREST:M/ELL�FOUNOATpN,SD• P10PERTY LINE Ti 1 <br /> eUMM ❑WIDTH IENOTH DEPTH DISTANCE TO NEAREST:WELL <br /> FOUNDATION PROPERTY UNE- <br /> DISPOSAL PONOS ❑WIDTH IENOTH DEPTH <br /> DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> I MEREBV CEPTIFY THAT 1 NAVE PREPARED TH18 ANNUC ATION AND THAT THE WOPK Y.'ILL BE DONE IN ACCORDANCE WITH BN JOAOUIN COUMY'ORDINANCES AND STATE(AWB.AND RULES <br /> AND REGULATIONS OF THE SN JOAQUIN COUNTY.HOME OWNER ORUCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING!'I CERTIFYTHAT IN THE PEMOEMNCE OF THE WORK FOR WHICH <br /> TO BECOME SUBJECT TO WOIKMN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY NV PERSON D SUCH A MANNER AS <br /> N THE PE <br /> WOFKM N'B COMPENNBA1TION LAWS OF C/AJFORN ANATURE CERTIFIES THE OWTHE APPICNT MUST NG:'I CERTIFY THAT(CALL 21 HOURS INPoXHIMANCADVANCE FOIL ALL REQUE OF THE WORK MR IRED INSR:TIONs.ICOMEPEETE DRAWING snow.PERSONS TO <br /> 7� I X�4-1T TITLE cf "^'O DATE: � L]- I [1 <br /> SIGNED% ��/ ))) AAA OV\ /1 VVV III � �� �� <br /> PLOT PLAN DRAW TO SCALE)SCALE---IO <br /> 4. LOCATION OF HOUSE BEWAOE DISPOSAL SYSTEM OR WOMBED <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. <br /> S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ON <br /> J. DIMENSIONED OUTUNE6 AND LOCATION OF ALL EXISTING AND WOMBED STRUCTURES, THE PROPERTY OR ADJDNINO PROPERTY. <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. _ <br /> PAymmm <br /> F�F�CIFlircn <br /> Li`� <br /> NOV �� '� <br /> SANJOAOUIN COUNTY <br /> PUBLIC HEALTIA HEAICES' <br /> FNVIRONME VITAL NEFl13HISH DIVISIE)b: <br />