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JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION _ P.O. BOX 988, 904 EAST WEBER-AVENUE, STOCKTON. CA 95201380 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compute in Triplicate) APPLICATION 18 HEREBY MADE TO THE BAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DEe PIBED. THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS //OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSMR APN/ C90 W. C.�� `^- ((++ CITY '"TZC/ _LOT SIZE_ OWNER'S NAME I71�GlWN ! /n F �.AT[. AOGRESS G. E.aJJ0PHONE CONTRACTOR L x-)(� LN:! MONE SUB CONTRACTOR ADDRESS mf PHONE TYLE OF SEPTIC WORK: NEW INSTALLATION REPAIRIAOdTION ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) PBM TFSTOI 1 1 HOW FOAMY AvNlmtivn INSTALLATION WILL SERVE: RESIDENCE 16 COMMERCIAL OTHER 13llll`J�� NUMBER OF LIVING UNITS:I NUMBER OF SEDROOMS: i' NWBM OF WPLOYM: I O (vim CHARACTER OF(AIL TO A DEPTH OF 3 FEET: e 1 MNSUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ❑TVPE/MM id- L_ L CAPACrrY T�(IrL//) /&On NO.COMPAvNMEN-rs PKO TREATMENT PLANT DISTANCE TO NEAREST: WELL loo,'T FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP '^BA/N,D OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING ME )4 NO.A LENGTH OF LINEDA /Eo 4 D 1 DISTANCE TO NEAREST:WELL FOUNDAmN PROPERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLMUNDATION PROPERTY LINE MOUNDED ❑W'IDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY ME pppOn &EVADE PITS ❑DEPTH 812E NUMBER DISTANCE TO NEARPROPE EST:WELLFOUNDATION PROPERTY LINE pfVn NE � SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONOS ❑WIDTH LENGTH DEPrH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS AP%ICATION AND THAT THE WORK WILLSE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS, AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER ORUCENBED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:N CEATIFYTHATIN THE PERFORMANCE OF THE WORK FORVMIOH THIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON IN OWN A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION(AWB OF CALIFORNIA.-EM L CONTRACTOR'S S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK MR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOBLMAN'6 COMPS! TION LAWS LIMIWIA.' THE APPLICANT MUST CALL 26 HOURS,IN ADVANCE FOR ALL rr��REQUIRED (I,NSS1PICTIONS. COMPLETE DIUWING BELOW. SIGNED% TITLE: `J'�I i`I C✓' DATE:_ l L/" 4 T PLAN(DRAW TO SCALE)SCALE :IC S. LOCATION OF HOUSE WA SEWAGE AL SYSTEMS,OS, OR PROMBED i. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PPDPERtY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON 3. DIMENSIONED OUTME6 AND LOCATION OF ALL EXISTING AND PROMSED STRUCTURES, THE PROPERTY OR ADJOINING PROPERTY. INCLUDR40 COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIXB. _ nJ \ O W. ll ,tp O xQAA 5 lJ- 0 �OJ E 1 \ O " O PAYME"T /2 D ot- pAY 151997 1 (, it7 j7c F SAN JOACgun uOUN i PUBLIC HEALTH_SERY(f-'FG.;......:__ ;....... FOR DEPARTMENT USE ONLY _ - - - APPLICATION ACCEPTED BY /T\ RDATE: AREA- DATE / / FINAL IN67CTONM DATE b I I �7 TANK,%T OR SUMP INSPECTION BV .�J,Q, QL ;7 ?DO /- �C ADDITIONAL COMMENTS: -<--221- )7 S V1C1+ � � 12 lT/f,(�! iv/'7k ZQ 45°6zv 5 ACCOUNTING ONLY: AIDF FAC/ PE CODE FEE INFO AMOUNT RMI I TED IECK// ASH RECEIVED BY DATE SRIPBIAIIT NUMBINVOICE BI Pub.Health Serv.-Enviro.174(3196)