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F ' S 3OA0UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION f *� a- P,O. BOX S88, 304 EAST WEBER'AVENUE, STOCKTON, CA 95201-388 �r 4 {209) 468.3420 "( NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS 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, JOS ADDRESSIOR APNf /it5r'o n ) `�! , CITY...-,_ 64 __ LOT SIZE OWNER'S NAME f �Lr7N L^L"t� -1�DDRESB '` Cr 2� PHONE Zd7 PONu7y /p.-5 C73 CONTRACTOR DDR ESB SUB CONTRACTOR � ADDRESS LICE PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION IND SEPTIC SYSTEM PERMITTER IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTI*1( I HOW MANY APPII�Man 0 INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL 13 OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKlOREASE TRAP ❑TYPEIMFO CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IFNCLOSED SYSTEMi LEACHING LINE ❑ NO.6 LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER SED 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH SIZE r NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE O HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES O AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AQENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTOFYTHAT INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGN TURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPE ION LAWS OF CALIF0�1[JIA.' TH CANT MUST CALL 24 HOIMe IH ADVANCE FOR ALL REQUIRED IN&PLCTIONe, COMPLETE DRAWING BELOW. (� 17 SIGNED X F � �� TITLE: c2LA-1 -�-- DATE: /I / PLOT PLAN(DRAW TO SCALE)SCALE Iu 1. NAMES OF STRE S OR ROA NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE OPE WITH DIMENSIONS AND NORTH DIRECTION. - EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTU AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON +. INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. �� si .. ..... .. .... : .. . .. ...: I .. .. C� '1... . .. ..: Jilt I,.. .. jH6:L r4Ea.;Lz" it 3 1-"� - FOR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY - _ _ DATE: a /13 �_AREA: '"` TANK,PIT OR SUMP INSPECTION DV DATE r I FINAL INSPECTION BY DATE ! ! ADDITIONAL COMMENTS: , ACCOUNTING ONLY: AIDE FAC#' PE CODE FEE INFO AMOUNT RLMI ITEO CHECKf ASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE f -� 3 035`N I Pub.Health Serv.-Enviro.174(3/98)