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JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER•AVENUE, STOCKTON, CA 95201388 .,. ., (209) 468.3420 ?e 1� C NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compl/t/In Triplicate) APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAGUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11110.3 AND THE STANDARDS OF SAN JOAQUIN CCO�UNTTYYPPUBLIC �HEALTH SEERRVICEEBB,,yEN�VIR�ONN�M-ENTAL HEALTH DIVISION. JOB ADDRESSOR APNf�(1"/�ClV/ f nr�l,,�\"� P I VL��}y-��i�i►/-�A, 1�1,-1��r�Ir�CyK�J�'C(C�IT�Y Ql(�\`+-J��JL.+`•�l`I LOT 912E(�j�T) OWNER'S NAME �M-�I��,/NL/�jyT�,FT\1J�1(�71�,�1 IW DDRE88 /C'��'IJ�.�(U�.�..-(:)A�Mi�e' f'C ►(S II/�^L�J w-�'�,PHONE ��`••� ►`�`� `I`M�) C.r. !^'11J� �, IM�. ADDRESS * 1'� 6 L11 VX K��I \ LICE 1Y�L -1 PHONE -1(47- CONTRACTOR 8118 CONTRACTOR ADDRESS UCf PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAJRUADDITION ❑ DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTW�I/{114OWM�ANY Andloatlon f I•��+ "TY INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS OR a a so PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE OPY LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMS LEACHING UNE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE ATS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY 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 AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. `, SIGNED X `�(y'-'�J►`N V l.1/C - ^�ll rya TITLE: DATE: 2'11 `-1" PLOT PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING 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, 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. _.... ..._..!.....`. .:... ..._......._. .....!.. ..: -. 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[' UG k1E/4LTI(3ERVIC$5 ENVIRONMDNTAL HEAL:H ......... .............'.......E...... ......[......`..... ...{........ ...;......i.... ,SIKH,..;...... .....:,.....;... ... . ......................... . .:..................:.... 41 FOR DEPARTMENT USE ONLY u APPLICATION ACCEPTED BY DATE: Ci C AREA: �z. f TANK,PR OR BUMP INSPECTION BY I ^p /� y�7 DATE / / 1 FINAL INSPECTIO ^ /'4' 1111�.E:-• ' G /gyp E ! / l ADDITIONAL COMMENTS: ,5 h Ll`'P S 4,3 -e O I efJ1 L"C l� 0 I C �C'�� 'ih I/�C(,.J I YlO- ��U( l 7'j5 r'3 — I e ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMI ITED CIIEC CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE f 2 553 l.l� a11q 90 t ' Pub.Health Serv.-Enviro.174(3(96)