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j q9 j i N.j "EAR JOAQUIN COUNTY PUBLIC HEALTH SERVICES INSPECTED gUT N ENVIRONMENTAL HEALTH DIVISION oT P.O. BOX 388 304 EAST WEBER-AVENUE,STOCKTO14.- MMI-388 PSIG r `al 12091 4683428 (� _7 a NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �+ (Complete in TFIPrMt$) APPLICATION 18 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TRU,, VCHAPTER 8-1110..E AND THE STANDARDS OF J SAMIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL NVIRONNMENTAL HEALTH DIVISION. JOB ADDRESSMR AM# ZZI Y/ CITY LOT SIZE - OWNER'S NAMEAl, /S Z✓ ADDRESS // / a LQ. / /O RONE ✓�] CONTRACTOR ADDRESS Me PHONE SUBCONTRACTOR ADDRESS NCJ RHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION Iff IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Ky, �/" P61C TFDTI.1 I 1 HOW MANY INSTALLATION WILL SOLVE. RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBFA OF(MNG UNITS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/BUMP SOIL CHARACTER: WATER TABU DEPTH B.INC TANKOHEASE TRAP ❑TY'PEIMFG CAPACTTY NO.COMPARTMENTS PKQ TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION MDPER LINE OFT STATION❑ SIZE TYPE OF RUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM( �I �. LEACHING UHF ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUND PROPO1j ITY � �� V FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUND N PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE NTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNERORUCENSEO AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE Of THE WORK FORNMICH 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.- CONTRACTOR'S HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I MAIM EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CA 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X TITLE: DATE: ROT PLAN ID TO SCALE)SCALE •to 1. NAMES OF STRUTS OR ROADS NEAREST TO OR BOUNDING THE P PERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE OPEATY',WITH DIMENSIONS AND NORTH DIRE TION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS. THE F ROMM OR ADJOINING PROPERTY. LU� I MAC.KVILLE 561 TFIT ~I L19ERTY ROAD "" \ I In o D Ij FARC.FL I ��I Z PR'> ED LOT LITE I IX to INSPECT p BUT NOT PAR—,EL,2 LIG Iz SI NEE N L EXI5TIN6 LOT LM - -r-- 4LR12 FOR DEPARTMENT USE ONLY �^ V APPLICATION ACCEPTED BY F//'`' / // DATE: EI Z ( Q TANK,PIT OR BUMP INSPECTION BY DATE I / FINAL INSPECTION BY ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDS fACB PECOO. F INFO AMOUNT RENUITEO IRC /CMN RECEIVED BY DATE SIR PERMIT NUMBER INVOICE( 1�. I Q" o o I SC�9 -Enviro.174(3/96)