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e JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Triplicate) 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,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.EbIVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI i / CITYLOT SIZE OWNER'S NAME ADDRESS'// PHONE CONTRACTOR ADDRES6T /{�]' �/��/iI� ,/� LK;I 7 �i PHONE 7 SUB CONTRACTOR ADDRESS TLS UC/ PHONE ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTNI I 1 HOW MANY Appllosdon S INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ 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/GREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE ^ UFT STATION❑ SIZE TYPE OF PUMP f SAND OIL SEPARATOR(ENCLOSED SYSTEM) EACN�fIO UNE i ❑ NO.b LENGTH OF LINES ` DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I ^ PI TER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE v \ MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION ti PROPERTY LINE 111 --a SEEPAGE PITS) ❑DEPTH SIZE :� NUMBER DISTANCE TO NEAREST:WELL G FOUNDATION PROPERTY UNE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I HEREBY 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 OF THE SAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X �� TRLE: �/�� DATE: P7 17 PLOT PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPO L SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL 8 STEMS. 3. DIMENSIONED OUTLINES 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 WALLS. THE PROPERTY OR ADJOINING PROPERTY. ... .......i......:... .. ....... . :......<...............r......:............:.. .. ._ .. .. _..;......:.......:......:.......:............................................._..........:.............>......:.......;.................... ..i......:i.......? .:..........: .. .... .. .. .. .................. ..... .. ... .... .5 ? . ...........".1....... ..... ... ....... ...... ..........:............................:....................:......: ......i.......:.......'.......i........ .. .:............. i i i i i i i i '• : .. .. ..' ....i......A......c.&...�.......�...... ......L.... .. .. .. .. .. ..... ME• .....i. ... ......'.. .........'.. ...........i...�.;................. - 6�d^9T _ : .. , ; . ..... °c,� ................. .... �,�,c ..,.. � QED ... ... . . 8 1997 .. . : ... `.. ...... ... :UL: : : JOAUUIN COUNTY UO T. ....... ............. ...L...;. .. .. MENTAL HEALTH 'SERVICES S1np' .......... ..<........ ...............�, _. ... . ..