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APPLICATION FOR LIOUIO WASTE PERMIT SA- JOAQUIN COUNTY PUBLIC HEALTH S_ VICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICtmpbtt M TOP11"t6l APRgATgN IB HEPo:BV MADE TO THE BAH JOAOIRN COUNTY MR A HERMIT TO CONSTRUCT AND,OR INSTALL THE WOR(DESCRIBED. THIS APPLICAMN 19 MADE IN COMPLIANCE WITH SAN "AWN COUNTY DEVELOPMENT TTITUL CHAPTER 9-1110.3 AND THE SS'TANTIAMS OF SAN /Ap"MN COUNTY HEALTH ERVICES.ENVIRON CNTAL HEALTH dVR10N. /Cl ! ! /tN !/vK cC EI�✓�BI�C' Clry LOT 61zE Joe AoonEs9roR APNF_� -T . 1 ,AL ,AL 11� y1� / 514-- ADDRESS !/ RM)NE O OWNER'S NWF 11My`Q /u'l 'lJ ADDRESS 12- C- .1/ TTL lKIL Z��RgNE 6 S3�/� CONTRACTOR n�' `��L� � �" ADDRESS ID, RHONE ADDRESS SVS CONTRACTOR TYPE OF SEPTIC WORK: NEW IN6TAl1ATOM REYANVAOMMM ❑ Du TRUCTIOM ❑ SIO SEPTIC SYSTEM PEFJAITTED IF RIBLIC BE !R 19 AV SLE WITHIN 200 FEET OF BUILDING.) RIC TFIT"I I I HOW MANY APp1lsSen INSTAlUT10M WILL MFOY : RESIDENCE COMMETHCIAL ❑ OTHER ❑ NIMSDI OF))INTO VMTI:� NUM FH/OF S,E.D_R�OOyM_S: ��/ MUAmFT OF FMROYEFI: i OF SORA TO A DEPTH OF J EEET' /O j }�RTBUMP SOIL CHARACTER: /��/�, WATER TABLE DEFTH /S {EPTq T ILp1FAlE TRAP ❑TYPE�MFOI A p-e. STAT� _CMACRY ( �vr= _NO.COMPMEMEW S .� �f' FOUNDATION (Q i PEKIPERTYIINE�- P%G T1IEATMENT PLANT 11 DISTANCE TO M APIEST: WELL T TYPE OF RI MP SAND OIL SEPARATOR IENCLOSM SYSTEM) SO i DFT STATION I] RAZE �_� N �"� ' FROPERIY ME LEACRNO UNE NO.t LENGTH OF LIMA �—IOD Iz�it��, d6TMKE TO NEME9T:WELLY=�_FOUHDATgN FILTER SED ❑WIDTH LENDTM DEPT" DISTANCE TO NEAREST:WELL FOVNDATgN ENOPERTV UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNOAMN PROPERTY ME SEEPAGE RTS ❑DEPTH SITE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BISAPt ❑WIDTHLENGTH DEPT" DISTANCE TO NEAREST:WELLFOUNDATION PEHO LSM DI6rotAl ORAD) ❑VIgTN IFNOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROFERTY ME - It HERESY CERTIFY TNAT I NAVE PREPARED THIS APPLICATION AND THAT HE WOR(WILL SE DONE N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RIMES AHD RI:OUTATIONS OF THE SAN JOAOUIH CO EOWNEA OR LICE :9 AM S1OHATURE CERTMIES THE POLLOWMq:')CERTIFYTHAT MTHE PERFORI.IANLE OF THEWOIK F0IIWMCN TWO PEANUT 1 .1 BILILL HOT EM0.0 ANY EER N m SUCH A MR AS TO BECOME 9UILIECT TO WORKMAN'S COMRNSATION LAWt OF CALIFORNIA. CONTRACTOR't HNKM DR 6VS.COM ING AT SEES E FOLLOW) :'I CERTIFY H T m THE fS 24 �O N ADVANCE POLI ALL REQUIRED OF THE MRK MR WHICH TdI9PECTON�S MWIT IS ICO�MRETE DRAWING O�WR. SVSJFCT TO WOIKMM't COMRNB T f�RMA.' T 1 Y ITT LE: DATE: BIONED% ROT RAN IDRAW TO SCALE)SCALE_ In 1. NAMES OF STREETS OR ROADS NE T R SOUNDHNO THE FRORMY. 4. LOCATION OF MUM SEWAGE DISPOSAL SYSTEM OR PROPOSED T. OUTLINE OF THE PROPERTY,WITH DIMENSIONS ANO NORTH DIRECTION. E%PAMK)N OF SEWAGE DISPOSAL SVSTEM9. 9. DIMENSIONED OMMtS AND LOCATION OF ALL EKISTIHD AND FROMSED BTRUCTUZ6, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FMTY R.ON NCLUDING DOWNED MEAS SUCH AS PATIOS,DRIVEWAYS,AND WAULS. THE FNORRTY OR ADJOINING PROPERTY. — Ccs- Y<s9arril.E �sceta�c -- 1all r � L e `t _. a i ...........