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APPLICATION FOR LIaUIU WASTE PERMIT SAN-JOAOUIN COUNTY PUBLIC HEALTH SERVICES 16` ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVE=NUE, STOCKTON, CA 9520 12091 488-3420 4 I 11ON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED �J (CRHGpIRta in Triplieah) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Al f'7 ', L/ 7 JOB AODRESSIOR APNNO J / /' �L 1 V -� .2 G'"- �/ .` - - CITY �a'>�%�. G•�_-l.- LOT SIZE OWNER'S NAME /i//%L� + �C! !? �r!7 / J / r� 7 - ( 1/ ( ADDRESS � tr / )",Ivo, r!✓..�C.'"G� ��1�4� PHONE � �-) L� T CONTRACTOR f i J f G'SC �7 ADDRfS6 /� �� C."]T ' !� r'� ��" �'�� Llcs_ � PHONE f>1 Ji (GG SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DFATRUCTION ❑ -.A Z.NO SEPTIC SYSTEM PERMfTTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PMC TEST191 1 1 HOW MANY Application 0 INSTALL-ATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMnER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF rMPLOM$: CHARACTER OF SOIL TO A DEPTH OF 3 FEET; PITISUMP SOIL CHARACTER: WAVER TABLE DEPTH 1.�1 6EPTIC TANKIOREASE TRAP ❑TYPE/MFG CAPACHI( NO,COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL. FOUNDATION PROPERTY LINE LIFT STATION❑ SI7E TYPE OF PUMP SAND OIL SEPARATOR[ENCLOSED SVSTEMI LEACHING UNE ❑ NO.6 LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED 11 Mum LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITA ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 019PORAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 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 r' AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-ICERTIFY THAT IN THE.PERFORMANCE OF THE WORK FOR WHICII T141S PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORWMAN'S COMPENSATION LAWS OF CALLFORNIA.' CONTRACTOR'S HIRING OR �. SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH TH19 PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFNSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 74 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPLETE DRAWING BELOW. J SIGNED X_�•�L_ TITLE: /�._�/,�~ DATE:44 - �(f' I•! PLOT PLAN IDRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4- LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYMEMB, 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 ARFAn m1rta ae r,a..-.� ..._.... {� 71-1-rlo-rl {f,x]r}I]A-I3 AA,x Il:�ll0.N AAiA LMA URRY i 9NW!/OVAIAp nFJRf nw YAx OI'q}'FH N O'l 3'50' E 2644,9' I I r {Ph IA}rrt�r! I r� ar,h,]aF IS T � ' 1 � N PARCEL NO. 1 QI PARCEL NO. 2 p # - 24.41 ACRE-NET 50.7t ACRES-NET n t � �: m I z � ' z N 1 eu.0/EOVIP1tENT m 1 BU�I➢PAC !� Z I uoer4E ualE !�/✓I aPwsL ti•!�. . �x]II-r10-(y1 „ATE" I-aL ,y {PN l!}!T• tr1A5Lr5 r.cvwc //ss�� b PIIMP PtnlnnuC LJ p FYltq wry- lY/ WORLE kpu{ I UNION ROAD sEPnc s+s1Eu ";�?''i '0 tel.x•Ya . ORrw.AT N 0'15'00_ E 2320.2' _ •v LAI $ i avn]!.1-v7i.wP� "'i A.x!t-rvs I = � Avm RxIIu A aLIaA•!w r]pAS 4R l '1991 Z A [� w Q I ,f {Px.]zl-yap-n av,c Asa-�sc-v — I > f11 , 1aFOUIN GQU tz li rfW4KA�I -NTAL HEALS-ICES I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: AREA: � yy_ TANK,PIT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION BY1 r L'1 -L--Lha ° L.° DATE J ! do ,_/ F / ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FAC# PE CODE FEE INTO AMOUNT REMITTED HEC !CASH RECEIVED BY DATE SR I PEWIT NUNIBER INVOICE# 15 6 1` "-