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NVIMMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NObRfFUWARM P€ 81 T lXMfttf 1 YEA 0'F 0 DA s 0 D �tel <br /> APRLICAtOONISIIEREaYMADEToE BAN JOAOIAN COUNTY FOR A PERMIT TO COLNSTPRUCT6'0 ANO PTflp�STALL THE WORK DESCRIBED,TNAPpl1CATgN 19JOAOVIN COUNTY DEVELOPMENT TITLE,CHAPTER0.I 110.5ANOTHE STANDARDS OF MAN JOAOIAIPCOVNTr so PVaLC HEALTH SERVICE AMENTAL HLAL7H V)SION. <br /> Jos ADDRESBRfl APHi {/ •� � /a <br /> CITY LOT K2F c�& <br /> OWNER'a NAME __.�/�C[: �7.�. , <br /> /,�y�� 1 /J' ADORES! fr `J C4'is J PIaHE <br /> CONTAACTOR--N-laA 1)!41 a�1' ls:. „_�,.AOOREBa /�/ LLi1L�r.// f• L; <br /> L'CSUBCONTRACTOR iPNONE •J.? <br /> ATNORE86 LICi <br /> I� PIIJNE <br /> 7 YPE OF SEPTIC WORK: IYEW IIPSTALLATION D REPAIRIADDITION <br /> BIEITROC"ON O <br /> O SEPTBEPIK BY87EM PERMIRED IF PUBLIC SEWER IB wyA111UI1E WITHIN 200 FEET OF BUM,p1PIG.1 <br /> Cy / PIRG TFATI.I I LHOW MANY <br /> INMTALIIITION WILL SERVE: RESIDENCE Cy COMMERCIAL[3OTHER Q ,G AN*-d-I <br /> NUNOILiI'OF LIVINGLIMTi: NIAMSIR OF EFaRGOMl: NLNY91 OF BMPLOY6S: •�� <br /> �_,�ITAIMGT O/800.TO A DEPTH OF 9 FEk7: 80G CHARACTER; WATER TABU D { . <br /> `^ lEPTIC T <br /> --TRAP ITYPEMFn .GJ EPTI <br /> .. CAPACII'I • -. .� s POC HO.-..F-..E.. �- <br /> FKO TREATMENT PLANT.(3 MIANGB TO NEAREST; WELL �j� "'� FOUNDATION.fa PROPERTY UNF f t i <br /> UFT STATION© G72E TYPE OF pUMP SAPID OIL SEPARATOR IENCLoeED SYSTEM <br /> LEACHING LINE 91NO.•L#NGTN DP LNNEB I�� ^' <br /> DISTANCE TO NFMEMT:WELL/ d i'./ FOUNDATION 7C M*pERTY LINE dojo r <br /> 11118%BFO 0 MDT" LENOTn DEPTH DISTANCE TO NEAREST;WELL <br /> MFOUNDATION WiOP£RTY LINE <br /> OLSNDEO 13 ryDTn IEWGTH DEPTH .DISTANCE TO N <br /> EARFaTI WELL TflUNDATION pHOPERTY LINE <br /> SmANTE FITS 11 DEPTH 812E NUMBER DISTANCE RE <br /> TO NEASTI WELL FOUNDATION F"DpERTY <br /> SUMPS QWR1Tn. LENOTH DEPTH DISTANCE TO NEAREB7:WELL <br /> FOUNDATION PROPERTY <br /> DISPOSAL PONDS 0 WIDTH IELWTH DEF'TII DISTANCE TON HIDPERry UNE <br /> EARESTI WELL FOUNDATION PROPERTY LANE <br /> 1 HEREBY EFIT"LATKHN THAT I HAVE PREPAREDMN C THIS V.MME AND THAT THE WORN ,S of DONE IN ACCORDANCE WITH SAH JOAQU N COUNTY OREMN►NCEa ANO STATE LAWS,ANO RDIEa <br /> AND REGULATKITb OF THE BAN JOAOWN COUNTY,NOME OWNER ORLCLNSEO AGLM'S aKINATURE CERTIPIES THEFOLLOW WOs 9 CERTIFYTHAT W THE MWOMOANCE OF THE WoM FOFIWWH <br /> TFMB PERMIT N IEBVED,l STIAII NOT EMPLOY ANY PEAWN M SUCH A MANNER AN TO BECOME SUBJECT TO MRKASAIMB COMPENSATION LAWS OF CMX*FMA., CON rRACTbR•S HIRSq OR <br /> BUB CONTILACTINO SIIN7;uF CETTL IF{Es THE FOLLOWIZ-I CERTIFY THAT IN THE PEI�ORMANCE OF THE WOIK PoR WHKH THIS PETWIf IS NeuEp,18HALL EMPipY PERSONS SUIUECY TO <br /> MLOTKAIAH'M COMPENBATIPII LAWS OF CMJFOWSA.• TN! -I CERTIFY <br /> MUST CALL N"GUM IN ADVANCE FOR ALL REGLERED INMpECTN NS. COMPLETE DMWSIO BELOW, <br /> BIOORDA f{r4[✓ <br /> TITLE• PATE: <br /> PLOT R'LAN DRAW TO SCALE!SCALE •ro _ •••_-••• <br /> I.NAMES OF STREETS OR ROAD*NEAREBT TO OR aoUN01N0 THE PROPERTY. T . <br /> 7.OUTLINE OF 719 PROPERTY,WITH OIMENa1ONs AND NORTH OWCTION. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSER <br /> I.OUIENSIONOD OVTUNEB ANP LOCATION OF ALL EXISTING ANO PROPOBEO STRUCTUIIFS, - EXPANSION OF SEWAGE DISPOSAL SYSTEMs, <br /> INCLUCTNG COVERED MEAS SUCH AM PATIOS,DRIVEWAYS,AND WALLS. S.LOCATION OF WELLS WTENIH RADIUS OF ONE HUNDRED FIFTY FF,ON <br /> THE PROPERTY OR AOJOGMNG TTIOPERIY. <br /> _.. r.. ..,_...,, <br /> '`.. <br /> 3 x. joa' <br /> l.rrreT . <br /> ... ..: <br /> 4 ...,. :..... <br /> Y <br /> g <br /> d <br /> ..,.,....... <br /> ...: :...i. <br /> SC ... ..4.. <br /> ILL �. :..,. <br /> FOR DEPAIITMENT USE ONLY <br /> APPLICATION ACCEPT ED BY NATE: I Q <br /> TSM,PIT OR SUMP IMSPECTIOP BY DATE _ t 1 FINAL INSPECTION BY <br /> PAT E1 , 9 <br /> AOD{TIONAL COMMENTS: <br /> ACGOUNIINO ONLY: AID# FAC# <br /> PE cOOa FDS UHO AMOUNT RO.MITED CIO:CKFICAa" RECFNED■Y DATE SRI"MOT NULtRUL <br /> J1/6 b~ INYGII So <br /> C�/6 9'9Y <br /> Pub.HadM Serv.-E"W.774(W96) <br /> 1 <br />