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JOAQUIN COUNTY PUBLIC HEALTH SERVICES 000Z 70 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> r.1N <br /> P.O. BOX S88, 304 EAST WEBER AVENUE, STOCKTON, CA OMI-388 <br /> (209) 468.3420 <br /> NOR-REFUNDABLE EERMIT EXPIRES-t-WAR FROM DAIE ISSUf RI <br /> (Compbtt In TripDau) <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE= <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br /> /ENVIRONMENTAL HEALTH DIVISION. } <br /> "JOB ADDRE88IOR APN/ L4 6_� C.0 stcity C V ...,... CITY �1-17!-- �` 1 ,LOT SIZE If <br /> OWNER'S NAME van Q,C�SGI �.`5 ADDRESS S CWk•e— PHONE <br /> CONTRACTOR �� -•r- /1 /} <br /> ADDRESS I~� R1C��' �I� �LICtl 'S pHpHE�� <br /> BUB CONTRACTOR ADDRESS UCI PHONE <br /> 'TYPE OF SEPTIC WORK: NEW INSTALLATION Y REPAIMADDITION ❑ DESTRUCTION❑ - <br /> i(NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING.1 PERC TESTI.)( L HOW MANY <br /> Applloatlon f <br /> 3 <br /> 'INSTALLATION WILL SERVE:- RESIDENCEiG COMMEfiC1AL❑ OTHER❑ <br /> 'NUMBER OF LMNO UNITS,_. j_,_ NUMBER OF BEDROOMS: � NUMBER OF EMPLOYEES: A 1 <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: CX) PIT/SUMP SOIL CHARACTER: -S GA J. WATER TABLE DEPTH <br /> SEPTIC TANKIMEASE TRAP EfTYPEIMFO _2 J:L_ _ G2f1 Gi Cf&;PACITY 1 [S b NO.COMPARTMENTS <br /> ,FICO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL_j0_Cj! FOUNDATION f A I . PROPERTY LINE.__ l: <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) , <br /> 1 <br /> LEACHING LINE O'NO.d LENGTH OF LINES - 'WF-'' - DISTANCE TO NEAREST:WELL—Loaa FOUNDATION' 10 ' PROPERTY-LINE166 <br /> FILTER BED E]MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED �13 WIDTH LENGTH 'DEPTH' DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEEPAGE PITC tKJ DEPTH 8RE 3 to F NUMBER DISTANCE TO NEAREST.WELL�T FOUNDATION j PROPERTY LINE 310' i <br /> SUMPS 13 WIDTH LENGTH DEPTH .DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE O <br /> .DISPOSAL PONDt ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> #kEREBY 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 <br /> AND REODUITIONB'OF THE SAN JOAQUIN COUNTY,HOME O WNER OR UCENSEO AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMA14CE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,- CONTRACTOR'S HIRING OR <br /> SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFO IA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INGMT10Nt, COMPLETE DRAWING BELOW. <br /> SIGNED X TITLE: f-'G_c a I` DATE.'- <br /> PLOT <br /> ATE:PLOT PLAN(DRAW TO SCALE)SCALE 'to <br /> ,l. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,,WITH DIMENSIONS AND NORTIf DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY, <br /> .,.. ............:... .. .. - .. .. - . <br /> ..............:.....:... .:..... .. .;... .:.. .. .. .. .. .. . <br /> r <br /> . . a . <br /> . . <br /> Er ..... <br /> .. <br /> ..... .. . <br /> ... ..;.. . <br /> :.... ... . .. . .. <br /> - I <br /> i <br /> .......:.......:.............:............{......:.,. .. .. <br /> ...y- ....,. <br /> 1 Y <br /> ........;... <br /> ......,....... ..................1 I <br /> �r <br /> 3 <br /> : <br /> ;. 3 : .. <br /> D <br /> . ;- s........ .. <br /> >.....;. .. ... <br /> :.. <br /> p. <br /> ...,..; .. <br /> .........., .., .. <br /> BE 1897 <br /> . . ................. <br /> : . <br /> ..-... <br /> NITr LH1AL H D 'SkQN <br /> PUgLI <br /> FOR DEPARTMENT USE ONLY '`' <br /> APPLICATION ACCEPTED BY fe�JV =�Nri/O'�� DATE: AREA: CZ <br /> TAMC,PIT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION BY DATE /21-29,9' <br /> }� <br /> 'ADDITIONAL COMMENTS: 11�t7 .�C3�l�.Q-„•,_C"!� �,,,__� C� D .� � mss.. _ -� ;j <br /> 3 <br /> ACCOUNTING ONLY: Y AID( FAC( y <br /> pE CODE FEE INFO AMOUNT REMIITED GHECKI ASH RECEIVED BY DATE SR I PERMIT NW013R INVOICE i <br /> 19'12 3544 1,6 t a;;)-50 G <br /> Pub.Health Sere.-Enviro.174(3M) <br /> f <br />