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APPLICATION IOUIO WASTE PERMIT SAN'JOAOUIN co, PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OIVISION P,O,Sox, 304 EAST WEBER AVENUE,STOCMTON,CA 95201388 (209)488-3420 NON REFUNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IGmpkis iR Trollestsl APPLICATION IB HEREBY MAGE TO THE BAN UOAOUR.CWNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAWIH COUNTY bEVELOPMEM TRIS,CHAPTER9.1S•�110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC H ERVICEB,ENVIRONMENTAL HEALTH dNBgN. JOB ADDRESS/OR APNB_ O r7 )CJ ^ l I ��r-�.A'VL.V C�%R��B;�� Y S l p LOT SIZE OWNER'S NAME 1 LC,,'T��-f• 1 N! r lz J ADORES8 7 C l�r4.A,i2` �/ ')f,[TbJ '15 Z-15ggNE S�i` CTEwlDlesa� C. �I�,y�OL O��YT9UGr0/ ADDRESS N S�1 1 ^ v `�5 L 1 S ucB \ PHONE � SUBCONTRACTOR ADORESB 'I(� �I�,✓(1 -&4-- LICE PHONE I TYPE OF SEPTIC WORK: WlV^W LAL"Rl0N-E3- REPAIR/ADDITION❑ DaTRUGTow❑ DN)SEPTIC SYSTEM PERMITTED IF PUBLIC�SEEWER 18 AVAILABLE WITHIN 200 FEET OF.OOF SSVILDINO ►BIC TESTI�1 1 I NOW MIWY INSTALLATION WILL SERVE: RESIDENCE L'7 COMMERCIAL❑ OTHER L] ''�/' p,�.�1•--� M p� "��°a�R M 5 9� -I NUMBER OF LIVING UMTS: NLMNER O\yF f,C iSEDROOMS: NUMBER OF ITMPLOYEES: CHARACTER OF 601E TO A DEPTH OF J FEET: PIT/BUMP BOIL CHARACTER: WATER TABLE DEPTH U � SEPTIC TANK/GREASE TMP 11TYPEMFO r4 /A CAPACMY NO.COMPARTMENTS PKG TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF RUMP BAND OIL SEPARATOR IENCLOSED SYSTEMI LEACHING UNE ❑ NO.A LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PPOPERTY LINE I FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH IENGTM DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE FITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DfpTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THATI VE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUN COUNTY ORDINANCES AND STATE LAWS, D MULES AN AND REGULATIONS OF THE SAN JOA WIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORM OF THE WORK POp WHICH THIS PERMIT IB ISSUED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB{ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY TRACTORS HIRINGBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOW IN ADVANCE FOR ALL REQUIRED I""WTIONS' COMPLETE DRAWING BELOW. <B&SHEDx_ICna�Lf) � �) 1r/JT.-L TfflEl •C.� DATE:]- 7-96 PLOT PUN(DRAW TO SCALEI SCALE /1( 'IS 300 1 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED E.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, E%PANBION OF SEWAGE DISPOSAL SYSTEMS. B. ISIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, B.LOCATION OF WELLS WITHIN RADIUS OF ONE HVNDIIED FIFTY FT.ON NO COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WAL%S. THE PROPERTY OR ADJOINING PROPERTY. Y L 4 I wL 0 U 'q Y h1 n o rI P $qlv Igg6 FNV l9 NMF T CQThsfq ' 1 .......... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY�...I DATE: (� `"� y Y AREA: TAMC,PT OR SUMP INSPECTION BV DATE / / FINAL INSPECTION SY • DATE ADDITIONAL COMMENTS: ACCOU......LY: AIDS FACS - PE CODE FEE INFO AMOUNT RUA rw �CfIBCwICMN NLS OM BY PATE T.7.NUAMBR INVOICE 0