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APPLICATION FOR UOUID WASTE PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION E 1✓ <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (CenPNt■In Tripkabl <br /> AFPLICATION,$HEREBY MADE TO THE BAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRICT ANDIOR INSTALL THE WORK DE9CRSED. THAI APf ATION IS MADE IN COMPLIANCF WTTM BAN <br /> JOAQUIN COUN!Y�/DEVH.OFMEM TRIS,CHAPTER 0.1110.3 ANO THE STANDARDS OOF RAN IOAOUN LINTY PUBLIC HEALTH SERV <br /> ICES <br /> S..E�1�M(/j1O NAFMTAL HEALTH DFVIeION. <br /> JOE <br /> OVv EIDI I��ERC_l-Y-- �TJF ��/ ���-� ��[�Gi t./W�- � CRV ��iJS �"� �T E� D +�Ie <br /> CONTRACTOR���"7na �iV ti-G- - ADORES,,/ �/ •C� r U ��FHONE 3�(3 <br /> DUB CONTRACTOR ADORE68 LIC/ FHONE <br /> TYPE OF SEPTIC WOR.: NEW INSTALLATION❑ REPNRIADd1IO DOHRUCTION❑ <br /> D40 FEPTIC SYSTEM PERMITTED IF FRIBUSEWM.ABLE <br /> C ER IB AVAWITMIN 200 FER OF IJXNG.I Fac royal 1 I w W MANY <br /> INSTALLATION WILL S6NE: RE61OEMv COMMERCIAL❑ OTHER❑ <br /> NUTA61 OF LENNO UNITS: NLSABSR OF"0000 NLSHBER OF EFAPLDYMS: / <br /> CHARACTER OF ML TO A DEPTH OF 9 FEET �� PR*UMP SOIL CHARACTER: WATER TABLE OEPIH_��+ <br /> SLPTM7 TANKIORIASE TPLAP ❑TVPvw-O CAPACDY NO.COMPARTIAEMS <br /> PCO TREATMENT PLANT❑ DISTANCE TO MEARIJT: WELL FOUNDATION PROPERTY LINE <br /> LIFT STATION❑�F�SUE TYPE OF EVMP S/y'ND OIL SEPARATOR IENCLOSED BYRTEMI _ <br /> lEAO1S1W LNE NO.•IENOTH OF LIHEBL�BOO -j�['f'P� - INSTANCE i0 NEAEEBT:WFµ/GeFOUNORTgM/G / PPOPERRY UNE/Q 0 / <br /> RILTER BED ❑WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST:WELL FOUP.DATION FROPFF Y UNE <br /> MOUNDED ❑WIDTM LEMTH_ DEPTH DISTANCE TO NEAREST:WELL FOLNOATION PROPERTY LINE <br /> S®AOe RTS ❑DEPTH BRE _RIMS" DISTANCE TO NEAREST:W FLL :OUIOATION PROPERTY LINE <br /> SRM►S Cl WIDTH LENOTH _DEPTH DISTANCE TO WAMffT:WRL bRT <br /> _FOUNDATION RPEY LINE <br /> DISPOSAL POM" 13 WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL!FOIR/DATXW PROPERTY UNF <br /> 1 HEREBY CERTIFY THAT 1 HAV[PREPARED THIS APPLICATION AND THAT THE WOR[WRL BE DONE IN ACCORDANCE WFTH"AN JOAOUIN COUNTY ORDINANCES AND STATE I AYYS.AND RLAE8 <br /> ANDMR" <br /> Y.No OWNEROR AJC ENSED AGENT'SMONATIM CERTIFESTME POLLDWNO:'I CtRTSY THAT N THE FEIFO~ANCE OF THIS WORM FDRWNSCH <br /> TNI NY N M SUCH A MANNER AB TO SECOME`BXCT TO WORCMA:'e COMPENSATION LAW*OF CAUPOR IA.- CONTRACTO W4 MONFIG OR <br /> `SCOFOLLO :'I CERTIFY THAT IN THE P EE3 AMCE OF THE W01K FOw WNCH THAN PERMR IS ISSUED.1 SMNUL EMPLOY PERSONS 8U6JECT TO <br /> RFII A. H[ ANT MUSY CALL 34 HORS{{IN ADVAi�'"a�A'4 REOURFD IMBPECTIONB, COMPLETE DRAWW40 SELOW. <br /> ` /IL/7 <br /> 12' /i <br /> STONE X // 4 TRLE.�/ GATE: � a <br /> PLOT FLAN(DRAW TO SCAUI SCALE_ _ <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. ie4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WRH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> O. DBAENI ZONED OUTUFE0 AND LOCATION OF ALL EX1911HO AND PROP06ED STRUCTWREO, S. LOCATION OF WELLS WAMN RADNS OF OTE MUNDAM FIFTY FT.ON <br /> INCLUDING GOVERNED MEAS SUCH AS PATIOS,DRIVEWAYS,AND WAILB. THE FROPERTY OR ADJOINING PRDPEFrrY. <br /> .. .. AAAA .. .. <br /> _�. .:. � y,a.. ... ... ... .,... ;. ... AAAA.. . <br /> !l i <br /> _ AAAA <br /> ............... r.. :... — <br /> flo .. <br /> I R <br /> All <br /> URAL <br /> III I( _........ ... -- GIC <br /> AAAA.. <br /> rY l7� SANO J <br /> i .. ...Pv�,� wN��N� 2 <br /> e�uvtgpN �e+�,rH aegv,cee <br /> /' _ _ ERLTN DIV18fOr. <br /> .. _AAAA.: - :AAAA.. <br /> . FOR DEPMTMdT USS ONLY II V <br /> APPLICATION ACCEPTED 8Y DATE: I O yl,. NIEA: 2 1 <br /> IANC,PT OR BUMP MSF ECTMN BY DATE / FINAL INSPECT /�-" DATJ -2y'/�6 <br /> ADDITIONAL COLAMErn 5. <br /> ACCOUNTII,O OMIY: A1DP FACS <br /> T.L PE[INF0 AMOUNT REFAITED HEC MH wr.D 8Y DATE SNI►BS,BT NUS�9R INVOICEIF <br /> S X15 1Y °O �f'¢o -l/! t7 <br /> S/ G�J2l�k7 <br /> PLD.HOHM Serv.-Envwc-174(3196) <br />