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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION O V /! Wo ' .7�- P.O. BOX M, 304 EAST WEBERMENUE, STOCKTON, CA 95MI-M (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complots In Triplitsts) .1CATION 18 HEREBY MADE TO THE SAN JbAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN a OUIN COUNTY DEVELOPMENT TITLL CHI A ER 9-11,1�110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. ADDRESSIORAPN# 1 ,)a�-1 Cl W� J� _C� --__CITY LSC-1�G1'L�'�� tot SIZE f_ � PER'S NAME I i ADDRESS i` J L� �z' PHONE_►'p:J) TRACTOR L� L1I�QIl� ADDRESS t'T i r K L%) . -Lice c� PHONE -I> wC�—f CONTRACTOR ADDRESS 1�N► (% �`j Zaj Z•— )y 10 UCf PHONE - E OF SEPTIC WORK: NEW INSTALLATION ❑ REPANVADDITION DESTRUCTION ❑ SEPTIC SYSTEM PERWrTTED IF PUBLIC SEINER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PRBC TEST(.){ I HOW MANY Appil"dan fALLATION WILL SERVE: RESIDENCE Fila COMMERCIAL❑ OTHER 11OBER OF LIVING UNITS: I NUMBm OF BEDR ]OOMS: V NUMBER OF EMPLOYEES: -� 7 IRACTER OF SOIL TO A DEPTH OF 3 FEET: J A ND PTJSUMP SOIL CHARACTER: SI�TT.s� _WATER TABLE DEPTH •I S � TIC TANKIGREASE TRAP ❑TYPE/MFG 1")11-15:Lj1N!- CAPACITY NO.COMPARTMENTS �r TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL iCv r FOUNDATION I��- - PROPERTY UNE Z LIFT STATION© SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI ry0157I CHINO ONE 15 NO.&LENGTH OF LINES I u O► DISTANCE TO NEAREST:WELL 1!JC t" FOUNDATION,PROPERTY LINE 4•_�p t0 ` f`- Q,� I 'ER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL. FOUNDATION PROPERTY LINE JNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE PAGE PITS 11 DEPTHSIZE NUMBER p DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINEq APS IH MOTH Z i LENGTH 1-2, DEPTH 1 r DISTANCE TO NEAREST:WELL 1FOUNDATIONS E�0 PROPERTY ONE .G•T�T " POSAL PONDS ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE ' REBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES I REGULATIONS OFTHE BAN JOAOUIN COU11M.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFI ESTHE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OFTHEWOPIK FORWHICH B PERMIT IS ISSUED,I SHALL NOT EMPLO5&ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR I-CONTRACTING SIGNATURE CERTIFIES THE POLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 113 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO �, } RKMAN'S COMPENSATION LAWS SOOF�CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED IIN�SP,EECCTION& COMPLETE DRAWING BELOW. NED X `s'f-�� TITLE: I F''F �i�(� DATE: 0 Z• -f PLOT PLAN(DRAW TO SCALE)SCALE ' NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES,' S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON NCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. A2 F3 :...,. - - .. .... ... .. . - ..;kc - ... ...... s U c' .... ��. .. ... . . . .. . e FOR DEPARTN�IT L119 ONLY----- - _ 'PI TION ACCEPTED BY DATE: AREA: PIT OR>IUMP INSPECTION BY _ DATE 17 1 iNAL INSPECTION BY DATE )OPTIONAL COMMENTS: _ '� ) ACCOUNTING ONLY: AID# FACS PE COVE FEE INFO AMOUNT REMITTED !CASH RECEIVED BY DATE BR 3 PERMIT NUMBER INVOICE e Pub.Health Serv.,Enviro.174(3196)