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APPLICATION FOR LIOIIID WASTE PERMIT S,-.RJ JOAQUIN COUNTY PUBLIC HEALTH SL—kV10ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468'3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompletB in Tdplkatd APPLICATION ES HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED, THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH BERVICIEB,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/0R APNi t' �,L ` -` I ` � �� C� �` ' / - �/,(LVOT 81�Z/E OWNERS NAME L)AV% R 1 L 1 i PV\ q�-�1/QS.I l�'C t.I�I�ADDRES8 1 f (� PHONE ry + ' + CONTRACTOR ��•R'IY�IIIyZ.OYIq-l'�I,�� ADDRESS V� C711 +I1 ((,d q - q vc, PHONE367� 76 I SUB CONTRACTOR ADDRESS UCi PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIA DDITION ❑ DESTRUCTION❑ [NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PWC TESTIS)I 1 HOW MANY ` AppBoodon 0 INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF WINO UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TA NKMREASE TRAP ©TYPE/MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ 61ZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSEO SYSTEMI LEACHING LINE ❑ NO.h LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER RED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE �} DISPOSAL PONDS ❑WIDTH LENGTH - DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE l 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 OF THE SAN JOAQUIN COUNTY.HOME OWNER ORUCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FORNMICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIFM OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•I 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 HOURS IN ADVANCE FOR ALL REQURjED,INfS/P1ECTIONS, COMPLETE DRAWING tBELO,OW. SIGNEDX�\ ILL( LliJ� __ TITLE: TP'�1R/' SGhV �� DATE: �[ " ^ _ PLOT PLAN IDRAW TO SCALE)SCALE •To 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. IDCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P'ROP'OSED 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 INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. i i ..........:.. .....L... .. .-:._...- - .... --- :...... ...., . r . � - l f2 .. - . .... .. .. .. .. .: ... .. ..-.... . .. . .. :. .. .. ....;.. : ...... _. .... �C VE0 - . SAN� _ _ SE H OSIS1014.... r, LI_G HEALTH- CNV FiONMENTA--HF A4 FOR DEPAItTMEMT USE ONLY APPLICATION ACCEPTED B DATE: z TANK,PRT OR SUMP INSP'ECTIO14 BY DATE I / FINAL INSPECTION BY DATE// I re ADDITIONAL COMMENTS:_ I As to_-3 Rv } ACCOUNTING ONLY: AID# FACS PE CODE FEE INFO AMOUNT IMMI ITED CHECKI ASH RECEIVED BY DATE SR!POD I NL> TER INVOICE 0 ,S— Pub.Health Serv.-Enviro.174(3/98)