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J1F' �vti Io"•""' - UO/C� _ �� f•-` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIE ENTAL HEALTH DIVISION ,.. P O.BOX 388,304 EASLwEBER AVENUE,STOCKTON,CA 95201388 - f,1(,7,�'U (las)asR-aazB r NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Urnpbq fD Trialk.t.) PUCATION 18 HEREBY MADE T THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN --.AOUIN COUNTY DEVELOPMETITLE, HAMER 9-1110.3 AN THE STANDAR 6 OF/6A JO//AOV11 COUNTY PUBLIC HEALTH SERVICES,ENVIIRROON�MIENTAL HEALTH DIVISION. �// ,. JOB ADDRESS/O ! L/' / �rol•/n�. - ,":: '� /—f'(�(q/J�( CfTY /"'(`/G.t/yllc/�EJ LOT SIZE rc/'J7L��C.. JNER'9 NAME /�•-�-/y �GT/".��' �`,/ ADDRESS�V /� c,�/ e Avc— l�Ct�/�- //77 PHONE INTRACTOR„ /v�V J`/YL ✓J�- ADDRE96IZI (�/�(.'C • // ,47'1<74l UC! �0 / PHONE G ✓ 4� SUB CONTRACTOR ADDRESS UC! PHONE TE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION❑ D SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PO1C TESTI.1 I I HOW MANY APdmeno�! INSTALLATION WILL 6EHVE RESIDEN COMMERCIAL 1 ER❑ -'•IMSE1 OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: �IIER OF SOIL TO A DEPTH OF 3 FEET{( RT/SU,.M�P�B4O(:j.L.CHARACTE •�` WATER TABLE DEPTH -(ANX/OREASE TRAP ❑TYPE/MFG �'XJr CAPACITY 1('L.•'O CTyANO.COMPARTMENTS OC PRO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELLS C/ 'y FOUNDATION ID ' PROPERTY UNE_�D — UFT STATION❑��--SIIZ��E TYPE OF F PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI �1 tom_ f \CNNO UNE pGL,NO.S LENGTH OF LINES p��U• I i/L,)",_ DISTANCE TO NEAREST:WELL FOUNDATIONAL/ PHOPLRTY UNE "TER BED /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE -OUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PITS DEPTHS '' � SIZE T//�"' NUMBER_ DISTANCETO NEAREST:WELL/_So POUNDATION/60 ' PRDPERTYLINE 76 1IRSPB ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE BPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE PREREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT T WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REO S OF THE SAN JOAQUIN COUNTY.HOME OWNER ORLICENS AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY-THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PMR IS IS D,I SHALL NOT EMPLOY RSON IN SUCH A MA AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR ::B fONTRACTiNG 6 NA 7 RE CE S E FOLLO NG:'I CERTIFY TH T I THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO OI�CMAN'6 COM ENS TIO W6 OF A IFORNIA.' LL 24 HOURS IN ADVANCE FOR ALL RE,U`�INSPECTIONS. COMPLETE DRAWING BELOW. / 6iGNED\X. //I TITLE: D C11 PLOT PLAN(DRAW TO SCALE)SCALE NAMES OF STREETS OR ROADS NEARES TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.UN IF INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 1 A i �7/ ,M t�cu4t 'z— �I rely; F. Nps 2 l `SEES moo/ lue FOR DEPARTMENT USE ONLY CATION ACCEPTED dV /( DATE: I AREA 15 �& T` R OR SUMP INSPECTION BY DATE` 1/7 / FINAL INSPECTION SV /DATE:( 1/I! �/ ADDITIONAL MMENTS: 'r ACCOUNTING ONLY: AID! FAC! 1 PE CODE FEE INFO AMOUNT REM((TED CHECK/CASH RECEIVED B\' DATE SR!PERMIT NIWFR INVOICE/ o0 6 !r z L _. Pub.Health SeN,-Enviro.174(3/96)