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SoAPPUCATION FOR UGUID WASTE PERMIT JOAQUIN COUNTY PUBLIC HEALTH Sr-RVICES ',,• i ENVIRONMENTAL HEALTH DIVISION 304 EAST WEEDER AVENUE,STOCKTON, CA 95202 . (209)468-3420 ` F ' Rf)R•REFURQABLE PERM EXPIRES I YEAR FROM GATE ISSUED ' F le T�plints) APPLICATION IS HEREBY MADE TO THE SRN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN .)DAWN COUNTY DEVELOPMENT TITLE.CHAFFER 8-11 1 O.3 AND THE STANDARDS OF SAN JOAONN COUNTY Pmm HEARTH BERVICE8,ENVIRONMENTAL HEALTH DFVIMON. ` �] JOB ADIDRESSIOR APN# I O`` 76, L W.{a J.n dT O reale -e. Ret CITY �}F� h ,q tO ' .R LOT SIZE 1 "CSL-� OWNER'S NAME /Q- -�1(XX {�{CL h e p f 0" ADDRESS_L�0,�y 2S I / h U P✓I -rC9 4 PHONE_109_ 7q-l-233�. CONTRACTOR �+ /�T/ /! '�. ADDRESS LIC/ - RHONE SUB CONTRACTOR - ADDRESS LIC# RHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAnuAbDITION ❑ DFATMXTLON❑ ANO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEW TESTIol 1 H NOW MANY + F INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER❑ NUMBER OF WINO UNTTS:—L—WN80t OF BEDROOMS- NUM8V%OF HMPLOYEEB: . CHARACTER OF WIL'TO A DEPTH OF 3 FEET: PTTISLIMP SOIL CHARACTER WATER TABLE AL SEPTIC TANK/OREE TRAP ❑TYPE/MFG C®h �i+A.- CAPACITY L'/�l_ FU o OL4L— NO.COMPARTMENTS y FPKG TREATMENT DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION TYPE OF PIMP SAND 0.SEPARATOR(ENCLOSED SYSTEM) f wry, y+ LEACHING UNE NO.4 LENGTH OF LINES l V© �� DtBTAFICf 70 NEIJSEBT:WELL S o E FOUNDATION •4O rr PROPERTY UNE 5 r FILTER BED ❑WmTH LENG'TT1 DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE F MOUNDED ❑WIDTH LENGTH DEFT". DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FNSPOSAi SEEPAGE RTS 11DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTYUNE SUMPS 13WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE PONDS ❑WIDTH LENGTH DEPTH _ DH.TANCETO NEAREST:WELL FOUNDATION PROPERTY UNE I I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPL.ICAT)ON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATLONSOFTHESAN JOAOUINCOUNTY.HOME OWNER OR LICENSED AGENT'S OGNATURECERTIFIESTHE FOLLOWING,,ICEATIFYTHLATINTHE.PETFORMANCEOFT14EWOW FORVVTSCH TFBB PERMIT M ISSUED.I SHALL HOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION GWS OF CALM MITA-- CONTRACTOR'S HIASNB OR LL --SUB-CONTRACTING SIGNATURE CERTIFIES THE FOUOWING.'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THM PERMIT 18IBWED,1 SHALL EMPLOY PERSONS SUBJECT TO WORCMM/'S C PENSAT LA OF CALIFORNIA.' 7 APPLICANT MUST CARL 24 HOURS IIT ADVANCE FOR ALL RECUTAED INSPECTIONS. COMPLETE DRAWING BELOW. F L DATE: PLOT PLAN{DRAW TO SCALE)SCALE 'to . NAMES OF STREET8 OR ROADS NEAREST TO OR WUNDONO 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 SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN WIDHUS OF ONE HUNDRED FIFTY FT.ON I Fl INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAY8,AND WALKS. THE PROPERTY OR ADJO04M PFADPO IY .,. ,...._ ._.- .,..... ... .. .. ... .. -. .. .. - - - - - ... :... f..... 4 ....... ..... ;1n1 obi[ .. . . .. ..... .. O !'r1 -� I .20 a ra'o 1.. ...:... :.. ............... ... .. :...... f ( . o&::::.:....... : ::: > .. ...... ..... n.............. ... .. .. .. .. ... E_.6��1? ... _ r'.. - ... ..... .o.. .r .. Dov a..�` .... .. * AN JOACIUJN C6UW Lt1. --� ...... r na ic�i1EALTN SF�i�VIS.... T' '.. ..... i ...:.. 1 1° r i - ...: r_•,� IAA!