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' AN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION ��41 �J,y RO. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA SIS201388 (209) 4663420 1/ NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.0 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADOREGBIOR APNE Yvo \/. P.1N `� CITY ��t^s 4 LOT SIZEy�RC_ OWNER'S NAME ADORF59�Q['1 v 1 c-,MN;'cA\ {FT�Ar 1\I 1L�I E 'Z27Q/ CONTRACTOR CS2 Y% e-X' ADnRE58 LIU PHONE 6UB CONTRACTOR ADDRESS LIC,_ RHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RFPAIRIADMTION DESTRUCTION IC ❑ (NO SEPUC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUIL UNG.) PFRC TESTIe1 t 1 HOW MANY ApPHeetlon f INSTALLATION WILL SERVE: RESIDENCE�( COMMERCIAL ❑ I.OTHER ❑ NUMBER OF"NO UNITS:1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:// CHARACTER OF SOIL TO A Df PTH OF 0 FEET: PITISUMP SOIL CHARACTER: cat d� WATER TABLE DEPTH SEPTIC TANKI011FASE TRAP El Tv d- CAPACITY 210E6 4pLk\ NO.COMPARTMENTS LCL PRO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE RIFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR(ENCLOSED EASYSTEM) l LCHMO LINE � O.A LENGTH Of LINES ,? K �D DISTANCE TO NEAREST:WELL__FOUNDATION 1dPROPERTY LME FILTER BED ❑WIDTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE O MOUNDED [3 MOTH LENGTH��pp OWN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE RH J SEEPAGE TS Pr DEPTSIZE G 1 NUMBER_DISTANCE TO NEAREST:WELL FOUNDATION t)T PROPERTY UNE SUMPS ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE WSPOSAL PONDS ❑WROTH IPNOTN DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOPK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES 1 AND REGULATIONS OF THE SAN JOAQUIN COUNTY.NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FORWHIOH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTFVCTOR'B HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOWMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED�INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X e / &.-/ y- ---(Zz) TITLE: W 1�G DATE: 194Or;L 91 ROT PLAN IDRAW TO SCALE)SCALE 'b I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 0. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTUPES, 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. IF Qf e 0 0 cj* x .C3 a'C � j A, sr1pEl �vm } }� .24po,� C-\ -- .k FOR DEPARTMENT USE ONL D V [L APPLICATION ACCEPTED BY ryr�o..—� ATE: T AREA: TANI,T{ SUMZZP INN�SPECTIOH BY 1)l DATE /A/ I /FINAL SPECTION B1Y L DATE J ADDITIONAL CO.MEM S:_ I DY 12 L / 1f� W \ ACCOUNTING ONLY: AUDI FAG PECODE FEE INFO AMOUNT REMI I TEDIIECIUFIC SH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE 41111 034, 59v Pub.Health Saw.-Enviro. 174(3/96)