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SPA` 'TAOUIN COUNTY PUBLIC HEALTH f- + (ICES 1, _ ENVIRONMENTAL HEALTH DIVISIL_ 7�L 304 EAST WEBER AVENUE, STOCKTON, CA 99202 (209) I YEAR 20 COPY NON-REFUNDABLE PERMIT EXPIRES YEAR FROM GATE ISSUED IComPMtE In TripileBUi APPLICATION IB HERESY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.7 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIC�E)S,ENVIRONMENTAL HEALTH 130,11110m. JOB ADDRE6S/OR APfJI/I /O /Z`O �'.A/2LAN �ZyAD �r ,E 'CII'TUGTR��pN��`It MP LOT SIZE_ OWNER'S NAME /� c� E�1, ��j,YR A /I ADDRESS IT��Jr/� A) `e&lC/Q�f�+J�(�/%/'-'L^L�,C14/� /1��RIONE CONTRACTOR l / ICY RLI F'. _UCL R10NE 44�j SUBCONTRACTOR ADDRESS UCI R10NE TYPE OF SEPTIC WORK'. NEW INBTAWTION ❑ REPAIIIADDIT10N ❑ DESTRUCTION ❑ / (NO SEPTIC SYSTEM RN.ITED IF PUBLIC SEWER 18 AVAILABLE WITHIN 300 FEET OF BURDINO.I PERC TESTIH I I HOW MANY'/] APWwXen E SA -f -� INSTALLATION WILL SEINE RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UMTS:_ NUMBEK OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 2 FEET: MISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANN/OtEASE TMP ❑TYPFJMEG CAPACT' NO.COMPARTMENTS WO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ❑ NO.B LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PRORiRTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATEI PROPERTY LINE MOUNDED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE RTS ❑DEPTH mZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL EF DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REUVUTIONS OF THE SAN JOAMIN COUNTY.HOME OWNER OR LICENSED AGENT-11 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEPI.IIT IS ISSUED,1 SHALL NOT EMPLOY AND,PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO NORKMAN'B COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRNO OR SU"OMRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE W01K FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOWMM'S COMPENSMON LAWS OF 9APICANIA. THE APPLICANT MUST CALL 24 HO MS IN ADVANCE NFOR REOLAR�SPECTION$. COMPETE DELI 022 /k} SIGNED X Y'V N S. PP T PUN(DRAW TO SCALE)SCALE—A/ AIL I. NAMES OF STREETS OR FLAGS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PTOIOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANMN OF SEVI DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN FAM US OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED MEAS SUCH AS PATIOS,DPAFWAY9,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. �EIZC� i N �, `ocaT�nnJ (0720 9AA?zs41%/ ,eco . :o ..... iJ IHVf{A2 Yi Al HALT"?isvf.fln` �J 2 C FOR DEPAP MENT USE ONLY APPLICATION ACCEPTED BY 19 ""T/ _'`"� /- — DATE: ;7 AREA: 9 L ADDITIONALCOMMENTS: V !'OJ 00 I/ to II 'I T�o For 09 SUMP INSKCTIO14 By ATE / -�/ 1FINA{I� CTIO \ GATE l l J ACCOUNTING ONLY, AID) FACT JPE CODE FFE INFO AMOUNT RFFA ETED EC ICA6H 11 1111, BY DATE W/PB M T NVABB INVOIOE F Pub.Health Sew.-Enviro. 174(3/96)