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SAN JOAOUIN COUNTY PUBLIC IIEAI TRVICES ENVIRONMENTAL HEALTH DIV P.O.BOX 388,30.4 EAST WEBER AVENUE,STi5CKTON,CA 95201.38E (709) 40R-3420 NDN-REFUNDADLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TTplkets) APPLICATION 19 14EURY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTnUCT ANDKIR INSTAI L THE WORK DESCRIBED.THIS ARRICATION IB MME IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESS/On APNM��# [�i� �� CPP/ I LOT 812E �Q P910NE �1 ADDRESS CONTRACTOR_7/l! �'�G. ?/7 �C i, n Yl IJC(��/ �1 PHONE SUB COMRACTOR ADDRESS LIC! PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AOMPION ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTEO IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PFR.TESTI.11 1 NOW MANY — INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL'/l' OTHER❑ NUMBER OF LIVING UNITS: NUMHER OF BEDROOMS: .0 NUMBER OF EMPLOYEES_ CHARACTER OF SOIL TO A DEPTH OF 3 FEET: TPIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE-IMF J � ,c CAPACITY -+ NO.COMPARTMENTS PKO TREATMENT PANT 11DISTANCE TO NEARFAT: WELLL � FOUNDATION�r PROPERTY LINE..��1— UFT STATION❑ S12E TYPE OF PUMP SAND OR SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE IX NO.a LENGTH OF LINES 4�/- '-� DISTANCE 10 NFANEST:WELL�TOUNOATION��-"-PflOPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ,J SEEPAGE PTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SUMPS ❑WIOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ^v DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL_ FOUNDATION PROPERTY LINE (' I HERESY CERTIFY THAT 1 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 OFT HE SAN JOAQUIN COUNTY.HOME OWNERORLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:*ICFMIFYTHAT IN THE PERFORMANCE OF THEWOPKFORVMICH THIS PERMIT ISIS SUED,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 CO NTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR MI CH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIGNS. COMPLETE DRAWING BELOW. SIGNED TITLE:�� f _. DATE: PLOT FLAN IDRAW TO SCALE)SCALE 'tP 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING 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. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATIOEI OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUMNO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 1 r t it JUL 21 1997 ENVIRONMENTAL HEALTH PERMIT/SERVICES 3 �lv FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY / 1 • C-' _ L� DATE: AREA: ))/ TANK,PT OR SUMP INSPECTION By,1 IIDATE / / FINAL INSPECTION By ` `Uc-T—',1-t ATE 7 Iy l / ADDITIONAL COMMENTS: FACCOUNTING ONLY: A111/ _ FAC! FEE INFO AMOUNT RDNI IT ED CIIECK!/ ASI) RECEIVED BY DATE SR/PERMIT NUMBER INVOICE/ 5 Y �i 3 / L Pub,Health Sew.-Enviro.174(3/96)