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SAL AQUIN COUNTY PUBLIC HEALTH SERVICES ` k! VIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 35201338 (2091408-3420 NON•REFUNDADLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Completa In Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 13-1110.3 AND THE STANDARDS OF SAN JDAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOS ADORESSIOR DPN# ? f _LOT 8VE OWNER'S NAME ADDRESS CONTRACTOR �'i7 rI1C (�YlJ/r s 5 j� i.r, ADDRESS 'r ,J �.. S' UCI j�'fCi t]5— PF1i]NE 41• ..7 - SUB CONTRACTOR ADDRESS 1G-; UC# RiON7_ - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AOt4T;ON (,al DESTRUCTION {NO SEPTIC SYSTEM PERMITTLO IF PUBLIC SEWER IS AVAILABLE WITHIN 200 TEFF OF BUILDING.1 PERC TCF TIM I 1 HOW MANY' . fivallnnNan# INSTALLATION WILL SERVE: RESIDENCE 4 COMMERCIAL ❑ OTHER❑ NUMBER OF LIVING UNITS: 2_ NUMRER OF REDROOMM- NUMNER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF.3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH �❑ ^.. SEPTIC TANKlOREA6E TRAP ❑TYPF/MFG CAPACITY- --Q'J �l ._., NO.COMPARTMF:'ITS �_— T PKG TREATMENT PLANT❑' ASTANCE TO NEAREST: WELL FOUNDATION Y PROPERTY LINE_ LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR!ENCLOSED SYSTEM) [�} LEACHING LINE ® NO,&LENGTH OFL4I��NES DISTANCE TO NEAREST:WELL_,FOUNDATION�Q:__PROPERTY LINE_ FILTER BED 13 WIDTH IES DEPTH DISTANCE TO NEAREST:WELL FOUNDATION._ PROPERTY LINE q MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION_ PROPERT'I LINE v y SEEPAGE RTS ®DEPTH SIZE y NUMBER DISTANCE TO NEAREST:WELL �`c7' - �� NUMBER__Y lalo FOUNDATION PROF'ERTV LINE i SUMPS CI WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE 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 ORLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFYTHAT IN THE.PEnFOSMANCE Of I FIEWORK FORWHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION ION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED,-PMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONa. COMFLETEbRAWING BELOW, SIGNED X_ 'TITLE: N1f?,L - DATE: Gr'.7 PLOT RAN{DRAW TO SCALE(SCALE- 'to ' 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PIIOPERTY, 4. LOCATION OI;HOUSE SEWAGE DISPOSAL SYFTEM 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, 6. LOCATION OF WELLS WITW4 RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH.AS PATIOS,DRIVEWAYS,AND WALKS. THE RIOPEFTr OR ADJOINING PROPERTY. ., .:.. ... .. i E: 1 tom' Qv O A .... .. .. Q ; ..... 4 I .. � 0-1199? .:... t L'I :.. _ 1 I4 —a ..-. - -''- ` - - —FOR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY �. -ter N . DATE; AREA: A ,6OR SUMP INSPECTION BY r DATE L f I FINAL INSPECTION BY DDITIONAL COMMENTS:_ ACCOUNTING ONLY: AID# FAC# PE CODE ME INFO AMOUNT REMITTED CIfEC /CASH RECEIVED Bl' DATE SR I PERMIT NU IVRER INVOICE# _qQ10 tIl It$a- _ (,I�? +F , 2-L62 1 'INn Pub.Health SeTv.-Enviro.174(3/96) , J