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SI IOAOUIN COUNTY PUBLIC HEALTH SERVICES `.P ENVIRONMENTAL HEALTH DIVISION ... P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 469-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comploto in Triplicate) AP9CATION IB HERERY MADE TO THE BAN JOAQUIN COUNTY FOR A PERAUT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN "AWN COUNTY 10.3 N. JOS ADDRESSMR%!i LOEAIEM lE.CHAPTER/� JT,1/ A / STANDARDSA +gUQILN�C�OU{HT1V�Rr1�0,.L fKCIIHEALTH BERVICEB.ENVIIgNMENTAl HEALTH mVI/SI(OOT SIIE/�/ OWNER'S NNAEEI�I+wLyiywrjrl�(1^JJ /A �Fo-\�/'TPi�T'57 n— rg,--AADdO1RE'59 Jit py) 1"\�fi�LaVrI LIIV �1J�_/ /�{�y RgNE ,,.(�y CONTRACTOR_ r\!l 1 N1QMQ ! PJRWE:Tl `^-)AORR�. • f i L Fuze' 1 <�i tX''7C-. me 468 116 PHONE✓,I'^Jy SUS CONTRACTOR ADDRESS Me ATONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DIATRUCTION ❑ IND SEPTIC SYSTEM MMIITTED IF PUBLIC SEWER 19 AV UBLE LMTHIN 200 FEET OF BUILDING,) MM TEST(o)1 1 NOW MARY �/I 1 ,^/{A�.�n,/ �E N,Ea.tlon INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIALS OTHER Iq Y LP 1 � �� J� e -1 p NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS' NUM///BER OF EMPLOYEES: v1'Mf` CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITMUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPF-/MFG CAPACITY NO.COMPARTMEMB MO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION POPERTY UMEE� UFT STATION❑ 612E TYPE OF PIMP SAND OIL SEPARATOR(ENCLOSED BYBTEMIMOOR Ey �e LEACHING UNE ❑ NO.A LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PFIGPIEFETY ME FILTER BED ❑MOTIf LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY ME SEEPAGE ATS ❑DEPTH 812E NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISMSAI MNDA ❑WIOTN LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MEN BAN JOAOUIN COUNTY ORDINANCES AND STATE"We.AND RULE; AND REGULATIONS OF THE BAN"AWN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CEWIFIEBTHE FOLLOWING:•I CERTI IN'THAT INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB 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 SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO "1 CO NSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPETE URAWINO BELOW. ?' SIGNEDy( �1 � .' ^'� + ♦iii C Tau: DATE: PLOT PUN MRAW TO SCALER SCALE •IS J 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF(OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OU`H.NE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION!Be SEWAGE DISPOSAL SYSTEMS. `I 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROMISED STRUCTURES, B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT.ON Lll INCLUDING COVERED AREA;SUCHan P•T•^^ ^'- -' -- .. )PROPERTY. rwiBl.AiA,ro s,Nvv: v�.�Ir ux j I� au kcnW6�aaYx'•N.A WC (\Px ORPS[TWa/r.1 / /JJ V B'F••'�• Pmw4-n•t F,xmO I{.•YxV l f/.•n EEM M uY 11 l4tw',wxc ' I I IW;14LL PUL llm lu•IYX.w.Y�F�C 4v/S: N�'NtFXw Y,26 N45E C I ux OK��3rpE f ,.....Aa I (/ r PAYMENT dl�� - �e �' (•, YM)'A•• RECEIVED ox JUN 25 1997 14 ,._. y ;•..P ....�.. SAN.I UA WIN COUNTY PUBLIC NLALTHJA nI .._ENVIROIJMEF!TAL HE TJTHVDTVI ION ..+uAEn '...cw.es.L — 4 AIATD..FL SFrsr,nr FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY `=� DATE. /.JJ NI 7 A. TANK,FIT OR SUMP INSKCTIO14 BY DATE / / FINAL INSPECTION BY DATE / V ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID, FACE PE CODE FEE INFO AMOUNT RFMI I TED CITE E/CABM RECOVED BY DATE W/PERMIT MUMMIES INVOICE♦ Pub.HeeRh Serv.-Enviro.174(3196) 318 cfo J b/lJ 70 m, yti sac r„a op- VGCHu, , ..,y