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- .. •.. •�nr1A FCRIFIII <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIO. <br /> 304-EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete IR Trblketel <br /> APPLICATION IR HEREBY MADE TO THE BAN JOAQUIN COUNTY OR A PERMIT TO CONSTRUCT ANDAJR INSTALL THE WOK DESCRIBED, THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN <br /> "AMIN COUNTY DEVELOPMENT TITLE,CHAPTER 91110.3 AND THE 6TANDANIB OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DMBION. I <br /> JOB ADDRESSOR APNI l U (0 0 ,�„LJL0..0 <br /> LOT SIZE/ <br /> 1�IJ crry S�L /��„S <br /> n Com(/ - <br /> OWNER'S NAME 4 ADDflE58 Cj� Q. 1C `I�� JR` S�` <br /> / PHONE <br /> CONTRACTOR (L( y ADDRESS S LICF PHONE <br /> SUBCONTRACTOR �1tI rL TQ�f/ ADDRE66/,;?/ <br /> ucr zZ ^PHONE�G3S�y3 <br /> TYPE OF 6EPOC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DFITRUCTION ❑ <br /> RIO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDING) PFAC TESTIq I I IOW MARY <br /> .\E�[/ AeReatlen <br /> INSTALLATION WILL SERVE RESIDENCE❑ COMMERCIAL y \ OTHER ❑ �,,,,, �1"" 1 <br /> NUMBER <br /> BER <br /> CHARACTER <br /> OF OF 90 UMTS:_ NUMBER Of BED1100 IIY/// WISUMP SOIL CHHAORACT R OY;�SAn� WATER TABLE DEPTH �� ' T <br /> CHARACTER OF 6011 TO A DEPTH OF B FEET. 1 Q � � l r <br /> SEPTIC TANOOREASE TRAP ❑TYPJMFO CAPACITY NO.COMPARTMENTS <br /> "0 TREATMENT FLINT 11 DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> LIFT STATION❑�QSIZE TYPE OF PUMP S6AN0 OOIIL..SEPARATOR IENCLOSED SYSTEMI <br /> LEACHING LINE �NO.S LENGTH OF LANES 1-SSI I�C�/1 I.`DISTANCE TO NEAREST:WELL�Q4 _FOUNDATION PROPERTY UNE 1��/ <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED y❑,-W^DTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION mgPERTY UNE �l <br /> SEEPAGE MTS .EJ-IIEPTH�s DOE NUMBER_/DISTANCE TO NEAREST:WELL FOUNDATNIH TQ 1 RIOPERTY LINE P <br /> tmpg ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL MADE ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL POUNDATON PIORRTY UNE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RLGFS <br /> AND REGULATIONS OF THE BAN"AMIN COUNTY.HOMED OR LICENSED AGENT'.SIGNATURE CERTIFIES THE FOLLOWING:'I CEPTIRYTHAT IN THE PERFORMANCE OF THE WORK FORWMKH <br /> THIS PERMIT IS I6 I SNALL NOT EMPLOY ANY RRIO H A MANNER AB TO DEC M[CT'TO xN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIRNO OR <br /> SUR CONTRACT( mGN iF CERT IBES THE FOLLOWIN :'I CE IFN THAT IIISII FOPMANCE OF THE WORK OR WHICH THIS PERMIT 18 ISSUED,I SHALL EMKOY PERSONS SUBJECT TO <br /> WORLMAN'S CO PENBATO WS OF CALIFORNIA.• TI APPLIC T CALL 24(OURS IM ADVANCE FOR ALL <br /> JREQUIRED IN6PEC110Nt, COMPLETE OM4NNG/BELOW. <br /> SIGNED X TITLE: DATE: <br /> ROT (DRAW TO SCALE)SCALE_ 'le <br /> 1. NAMES OF STREETS OR WADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED //>• <br /> 2. OUTLINE OF THE PROPERrcMTH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 0. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDINO COVEPED AREAE SUCH AB PATIOS,DRIVEWAYS,AND WALKS, THE PROPERTY OR ADJOINING PRORNTY. <br /> V <br /> I I <br /> I , F <br /> h <br /> s trs,1,15 et 245 1 /few <br /> FOR DEPAPTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ✓ /�^���� DATE: G V_ AREA: <br /> TANK,RT OR BUMP INSMCTIOIJII BY /^ DAT�EI FINAL INSKCCTTIIOOjN BY-7/ DATE W O d <br /> ADDITIONAL COMMENTS: ZL E�STT /1 �C �l iL✓ � d"'✓� ""' 'Y Zut ``"' <br /> Accoue"NO ONLY: AIOI Pncl <br /> FE CODE FEE INFO AMOUNT IYUVT VTED ITEC /LASH RECEIVED BY DATE M/PERMIT NUMBER INVOICE <br /> f r - <br /> L-- <br /> Pub.HeeRR Serv.-Enviro.174(3/96) <br />