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�Q $ArjOAQUINCOUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION P.O. BOX 3133, 304 EAST WESERMENUE, STOCKTON. CA x5 i-M (209) 468-3420 LION-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TripRcetel APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELO ENT TITLE,CHAPTER D-1110.3 AND THE ST7�17 JOAQUIN COUNTY PUBLIC HEALTH SERVICES, E�1�ORR�ONNM�ENTAL HEALTH DIVISION. /, TOB ADTIAE$$roR +r ^ Cly C` `" Z` LOT Sk �U jp OWNER'S NAMEw ADDRESS PHONE� 2 G/ CONTRACTOR �� ---- __ADDRESS eb LICE a PHONE SUB CONTRACTOR ADDRESS LIC( PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION 0 DESTRUCTION ,INO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTIQ I 1 NOW MANY Appllmdon t 9NSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL 0 OTHER 0 oNUMBER OF WING UNITE; NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/OREASE TRAP ❑TYPE/MFO CAPACrTY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE R LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEMI r LEACHING UNE ❑ NO.h LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED 0 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE JWJ� MOUNDED ❑WIOTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE V SEEPAGE PITS ❑DEPTH SIZE - NUMBER DISTANCE TO NEAREST:WELL FOUNDATION 'PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS 0 WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE 1 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 GAN JOAQUIN COUNTY.HOME OWNER ORLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CEFITIFYTHAT IN THE PERFORMANCE OF THE WORK FORWHICH 0� THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR S SUB-CONTRAMNO SIGNATURE CERTIFIES THE FOLLOWING.'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPE TION LAW8 OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNE TITLE: DATE: PLOT PLAN(DRAW TO SCALE)SCALE 'to 1. NAMES OF STRE 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, 6, 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. V ....i..... ..- - .. .......:......E......;......;..... ... ..........:- ............................... .. .. ......?.... .... .. - .....:..... ..... ............ . .. .... .. a � (IcaJ.rg HEA :1 S CES...... PUBLIC FIE f,VI. . ONMENTAL NEALTN p#Vl�1.0 ....'...... :......'.....<............ - �NVIFi -�..�..��_.��_.----•rte-�_ ;, FOR DEPARTMENT USE ONLY - -�--_ - APPLICATION ACCEPTED BY DATE: �� AREA:Z TAMC,PIT OR BUMP INSPECTION BY ATE I I FINAL INSPECTION BY DATE b I I C17 ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID# FACM PE CODE FEE INFO AMOUNT REMIITEO HEC /CASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE• D L1� U a 6 V D 7�f v Pub.HeBfth Serv,-Envlro.174(3196)