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7 � � <br /> ` OAPPLICATION FOR RIOUID WASTE PERMIT <br /> N JOAOUIN COUNTY PUBLIC HEALT RVICES <br /> ENVIRONMENTAL HEALTH DNISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NOX-AfFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> paplets In Triplksts) 0� 5V 1 <br /> APPLICATION Itt HEFIEBY MADE TO THE BAN JOAQUIN COUMIFY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED, THIS APPLICATION IE MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUMY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STAN�OARDRl0F BAN JOAOUIN UNITY EALTH BERVICES.DMADMIENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR A1'TII _ r •� 4 � (��. / A) r Fry •t"- WT BezE •7 3 4C <br /> OWNER'>!NAME •✓YE'�sl-� ADDREse- D.2 <br /> CONTRACTOR ADOMSS4. yl' / � rL �- ��'S ELM CONTRACTOR ADDRESS_ � LIC! PFIONE <br /> TYPE OF SW"C WORK: NOV INSTALLATION❑ /1EP LWADAITION ❑ DESTRUCTION ❑ <br /> INO SEPTIC SYSTEM PERMITTED 1F P:JBUC OMER IS AVAILABLE WITHIN 200 FEET OF BUILDING.] POW TEBTI+]1 1 WJW MANY <br /> �f APO�e�Ilon s_,-, <br /> UNSTALLATMN WILL■HIVE: RESIDENCE 12fi COMMERCIAL ❑ g OTHER ❑ <br /> NUMBER OF LIVING UNITS: I MUM!`91 OF i♦EDROM Oi: 1J NUMR91 OF EMPLOYEES: � <br /> CHARACTER OF SOIL TO A DEPTH OF 3 PEET: FTTISUMP SOIL CHARACTER: WATER TAIILE DEPTH _ <br /> SEPTIC TANXJMEASF TRAP ❑TYPEJMfi9 CAPACrTY NO.COMPARrWNTS <br /> FRO TREATMEMT PLANT❑ DISTANCE TO WEARLIT: WELL FOUNDATION� —_ PROPERTY LIRE <br /> LIFT STATION❑ LNIE TYPE OF PVMP BAND OIL SEPARATOR?ENCLOSED SYSTEM! <br /> LEACHING LINE ❑ NO.A LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> FILTER BED ❑W16TH LENGTH DEPTH DISTANCE TO NEAREST:WEIR FOLK/DATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST:WELL FftUNDATIOH PROPERTY LINE <br /> SEEPAGE PITS ❑DEPTH MIE _NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SUMPS Q WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL _,FOWIDATION PROPERTY LINE <br /> DISMSAL FONDS [I VMTH LENGTH—,DEPTH, DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY UNE_ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOM VALL BE DOME IN ACCORDANCE WITH AM!JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULER <br /> AND REGULATIONS OF THE BAN JOAQUIN COUNTY,HOME OWNER OR LICEfiSED AOEWT'R GMATURE CERTIFIES THE FOLLOWMING:'I CERTIFY THAT IN THP PEP640 MANCE OF THE WORK FOR WHICH <br /> TWO PERMIT to MOLW,I RNALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS 1'O BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALMWRSA." CONTRACTOR'S HIRING OR <br /> BUB-CONTRACTINO MONATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK P054 WHICH THIS PERMIT IE ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN' SATION LAWS OF CALM'OTWIA.'-T1iE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR AM MOUIRED INSFECTIONR, COMPLETE ORAWDIO BELOW ,rf <br /> TITLE: DATE: A <br /> PLOT MAN IDRAW TO SCALE]SCALE m <br /> 1. NAMES OF STREETS ON ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH OWEHBIONS AND NORTH DfRECTION. EXPANSION OF WWAOE DISPOSAL VYSTLMS, <br /> a. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED STRUCTURES. B- LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> NYCLUDBJO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADMINIINI PROPERTY. <br /> a. <br /> -30 <br /> ... :. <br /> ...... <br /> , !ENT <br /> fW.I,UIC H T,� <br /> 1 HET L 4 L7H s <br /> � <br /> tI�VlAphl <br /> HkA... <br /> 7 <br /> CEPARYM£N use ONLY _ <br /> APPLICATION ACCEPTED BY � GATE: � � AT�'EA' -.21 il <br /> TANK,PR OR BUMP INSPEC H BY DATE _ I -_I FINAL INSPECTION BY / 'DATE'— � <br /> 12— <br /> ADDITION EATS; <br /> ACCOUNTING ONLY: AID/ FACAI <br /> Pt coot FEE INFO AMOUNT RUNITEO 101 ASH OMEFV D RV DATE Es <br /> �{2 2 06 l D <br /> Pub,HeGNA Swv.•Enviro.174(3M) <br />