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WJOAOUIN COUNTY PUBLIC HEALTH SERVICL _ ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE;, STOCKTON, CA 9SMi-388 (209) 486.3420 / NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICamplote in Tripliestel APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WFFH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEB,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# `/ Q I .. YT✓C. CHyZ LOT 812E �• :0,4--, OWNER'S NAME /��RA-42-M k'rr.5 �'- ADOREss CONTRACTOR_4 (T` YL -G,r�S`C- ADDRESS /ZJ—PHONE l C✓LL'�cf'`. C'I �.• �LACI - �-3 LI3 4' SUBCONTRACTOR ADDRESS LICI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RTPAJR/ADDlTI0N\Lf DESTRUCTION ❑ ANO SEPTIC SYSTEM PERMDTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUI ING,1 PERC TESTW I I HOW MANY A9dlwtlen• INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ .OTHER Ll NUMBER OF LIVING UNITS- ' NUMBER OF BEDROOMS: 7 NUMBER OF EMPLOYEES: z q CH ER OF SOIL TO A DEPTH OF 3 FEETL�i fF- 4 PTTISUMP SOIL CHARACTERG X' WATER TABLE DEPTH J ` 7PTIC TA KIGREASE TRAP ❑TYPEMFO�C_h'ytC�{, ' �,.2 4.4iCAPACITY_1 //��C� C� _ _R4l NO.COMPARTMENTS PK EATMENT RANT ❑ INSTANCE TO NEAREST: WELL C-- FOUNDATION �Q PROPERTY LINE 0 � UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR{ENCLOSED SYSTEMI 1 c LEACHING LINE NO.•LENGTH OF LINES�'� 2 x• `/yF, DISTANCE TO NEAREST:WEU-e e9'SZ�FOUNOATFON Q PROPERTY LINE S FILTER BED 1:1 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION 1 PROPERTY UNE- SEEPAGE PITS DEPTH 2S 812E I NUMBER ( DISTANCE TO NEAREST:WELL C��' FOUNDATION .[P PROPERTY UNE j SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THA 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 OR UCEN AGENT'S ,,BE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A M N AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'.HIRIHO OR SUB-CONTRACTING X4 NATUR E IF1ES THE LL : 'I CERTIFY T ATI THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP_N T1 N WS F CALIF .A.' 7H APPLICANT UST C LL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, COMPLETE DRAWING BELOW. t SIGNED X I TITLE: 'W DATE: 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, S. 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, .. .. `: . . SKID - : RT ' _ : - rc� . r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE: AREA: q _ TANK,PIT OR SUMP INSPECTION BY DATE,may!-.! I FINAL(INSPECTION BY 4-- ` �J DATE a / ! '77 ADDITIONAL COMMENTS:..— CYL.�t,v.�J Q.��. '� ©I 3 I •tom l 0fee `TTS-r.-LC ,�O�C'] ia/ IF ACCOUNTING ONLY: AID# FAC# PE CODE FEE INFO AMOUNT REMITTED CHEC CASH RECEIVED BY (DATE SR I PERMIT NUMBER INVOICE 6