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J • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> (/ ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 398, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 <br /> (2091 469-3420 <br /> AON•REFURIDAB E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComPlato in Triplicate} <br /> APPLICATION 19 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WIT+{SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER <br /> �9�1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEA}LT}H2OOlASION. y�r <br /> JOS ADORESSIOR APNI W r 1L� �Y. ��,QJ q r G�/ �//y CITY[ `r—CL <br /> �hh� LOT SIZE S["/�J0 <br /> OWNER'S NAME_ L:l� V'C"A\ If- ` `LCX �/ck RISS ( (L I l9 Ycc VJ f�Kc' �117R S'}'�� PHONE � -T l �p <br /> CONTRACTOR_ k.y Y E S Q V15 ADDRESS OC�a Lw,� L L IJC4► _ �(e-c'�c q <br /> " 1 _ lUo�[{ PHONE <br /> SUB CONTRACTOR <br /> ADDRESS <br /> LIC 9 PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIRfADOITFON DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVARJIRLE WITHIN 200 FEET OF BUILDINC.) PERC TESTIA 1 I HOW MANY <br /> APdlaedon <br /> INSTALLATION WILL SERVE: RESIDENCE;qCOMMERCfAL ❑ OTHER ❑ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: __ NUMREA OF EMPLOYEES: �y <br /> a CHARACTER OF SOIL TO A DEPTH OF 3 FEET: L FITISUMP SOIL CHARACTER:_G{C,L, WATER TABLE DEPTH Q <br /> SEPTIC TANKJGREASE TRAP ❑TYPEJMFG CAPACI'Tl' <br /> NO.COMPARTMENTS <br /> PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LIN£ <br /> LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) <br /> IaLINE NE _.pl Ii Cl I 1 <br /> u+� NO.a LENGTH OF LINER `� DISTANCE TO NEAREST:WELL 7.5 ' FOUNDATIDNpgppEg7y LINE SSU C . <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTHLENGTH ( � '� � DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE_ <br /> ~ SEEPAGE RTS -t�EPTH SIZE � <br /> NUMRER��_ DISTANCE TO NEAREST:WELL C>t FOUNDATION �(}t PROPERTY LINE �d (� <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE �1 <br /> DISPOSAL PONDS ©WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ` <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTI FYTHAT IN THE PERFORMANCE OF THEWOIK FORWHICH <br /> TH18 PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATMN LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> SUB-CONTRACTING SIl;NA URE CERTIFIES THE FOLLOVYO:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S LOM AT N LAWSNOF CALIFORNIACALIFORNIA' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURMW INSPECTION$. COMPLETE DRAWING BELOW, <br /> SIGNED X W ; TITLE: DATE: p <br /> n <br /> PLOT PLAN(DRAW TO SCALE)SCALE 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> F.& <br /> IOU, <br /> 0 b lu <br /> x' r ,l.. JAI 8 1999 <br /> r-N1114i�� u,�iFl`���?hL_ A ?F-� <br /> c iT�yFv t�' <br /> I C � <br /> n <br /> G <br /> C <br /> k. C( tr <br /> c,o ci, o's v c.c>VJ-) E {e cp <br />