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SAN 1QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 Op (2091469-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete M TTiplk*t*) 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, ,CCHAPTER 9-1110.3 SAND TH()EE 9TANDARDB OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNF-w /O L / //! {/ CI��l,I� CITY /C��G%"� LOT SIZE_ OWNER'S NAMEY/y1.1/777�✓��+j hlaE N Q� /N`ADDRESA ///7n' X11 D�/� l�I�, \ PHONE CONTRACTOR 4't T\ ��n n�T ADDRESS O" �Y�V UC/ ,,,{{{ ///�� R10NE SUB CONTRACTOR L. ADDRESS , �Z_� ,TLKI PHONE�� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AII.AA WITHIN 200 FEET OF BUR DING,) PERC TESTId 1 I HOW MANY APpll—doR III— INSTALLATION INSTALLATION WILL SERVE: nESIDENCE❑ COMMEnCiAI_ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT///SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ❑TYPElMFG /� L.� CAPACITY //}¢•/J' NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WT.LLG� FT FOUNDATION�`�- PROPERTY LINE S T LIFT STATION❑ SIZE TYPE OF PUMPSAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ,��5-,(�/NO.S,LENGTH OF LINES —7//yy� DISTANCE TO NEAREST:WELL FOUNDATION_ /PRDPERTY UNE FILTER BED U WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE D19POSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 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 SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION*. COMPLETE DRAWING BELOW. SIGNED X TRLE:� DATE:0 PLOT PLAN(DRAW TO SCALE)SCALE IO 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, THE PROPERTY OR ADJOINING PROPERTY, INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. •.qr .....°.......'.....y.... .. _ c. . .. . vc E i '• i i i i i i :. .. .. .. .. .. . i .. .. .. .. .. .;.. .:... .. .. .. . i- . .... i6/�^r i : . .: ;. i' i NT .. • ._.. ..: . .. 0 �— - ••8. J ;D AR .......... • �lVUNry ,, ... ��F.11tTM'�RV6CE3......•.... .. j .. .... FOR DEPARTMENT USE ONLY DATE: AREA: APPLICATION ACCEr'TED eV J� TANK,PIT OR RUMP INSI`ECiION BV DATE / / FINAL INSPECTION BY DATE `/ �L.J LM ADMIONAL COMMENTS: ACCOUNTING ONLY: AJ0# i FAC/ PE CODE FEE INFO AMOUNT RETMITED TEC A*H REC13VED BY DATE eR I PSIMIT NUMBER INVOICE o Pub,Health Serv.-Envlro.174(3198)