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APPLICATION FOR LIOIIIDASTE PERMIT PUBLIC HEALTH SERVICES SIi111 jDAQ=C0UVff NMENTAL HEALTH DIVISION gl!ZyIROAII++iENT� v AOAQ ,WUIN ST., STOCKTON, CA 95201-0381 � ` 12091 488-3420 lad NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete is Trip imtW APPLICATION IS HEREBY MADE TO THE SAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WRH SAN JOAQUIN COUNTY Di VELOPMENT TITLE,CHAPTER 9-1110.'3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DWISIOh. JOB ADDRESSOR APIC)_ D i,46 I.o Gr, CITY Tr _LOT KZE 3/4�rr-s OWNER'S NAME j /R mit 6C L G ADDRESS S/"O MQ PHONE �t t� CONTRACTOR /-Ty /A Q�� SO/S/ ADORESs 6 011A P4...�.,��To UC# /f9 AV FHQNE 17 SUB CONTRACTOR ADDRESS LIC) _PHONE TYPE OF SEPTIC WORK: NOW INSTALLATION ❑ RFYADUADDITION � O"TNuCTHON ❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC=SEWER IS AVAILABLE WTTHIN 200 FEET OF BUILDING-1 POW TWThI I 1 HOW MANY AppSo.NOR• INSTALLATION WILL SGWE RESIDENCE IN COMMERCIAL ❑ OTHER ❑ NUMISER OF UVWO UMTS:) NUMOM OF BEDROOM$: NU)BER OF EMPLOYEES: CHARACTER OF SOIL TOA DEPTH OF 3 FEET: C44?' PIT/SUMP SOIL CHARACTER: 4/ WATER TABLE DEPTH SEPTIC TANKfUREASE TRAP ❑TVPEIMFG CAPACNTY NO.COMP/JTTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPET Y UNE G LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSEO SYSTEM) �r LLi%CMNO UNE 0 NO.&LENGTH OF LINES_- 9•a LLC .S / DISTANCE TO NEAREST:WELL FOUNDATION O PROPERTY LINE-7 17 ` FALTER BED ❑WIDTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL F ItMATION PROPERTY LNE MOUNDED ❑WIDTH LENGTH__DEPT% TMST A%CE TO NEAREST:WEIl _FOUNDATION PROPERTY UNE r SEEPAGE PITS ❑DEPTH SIZE NUMBER 1 DISTANCE TO NEAREST:WELL _FOUINDATION PROPERTY LINE SUMPS XrWIDTHI_LENGTH O LIEPTH /' DISTANCE TO NEAREST:WELL__FOUNDATION PROPERTY UNE C DISPOSAL PONDS ❑WIDTH LENGTH DEPTH D46TANCE TO NEAREST:WELL_ FOUNDATION PROPERTY LINE f r I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W'TH SAN JOAQUIN COUNTY ORDI IANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIHES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE Of THE WORK FOR WHICH TH15 PERMIT 15 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORK,14AN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING 09 SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN TAE PERFORMANCE OF THE WORM-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 FDI•ALL REOULMM INSPECTIONS. COMPLETE DRAWING EELOW SIGNED X TTTL�: DATE: PLAT FLAN(DRAW TO SCALE)SCAL. 'to 1. NAMES OF STREETS 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 EXISTM AND PROPOSED STRUCTURES, 6. LOCATION OF WELLS WR-HM RADIUS OF OPE HUNDRED FIFTY FT-ON INCLUOING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PFIOPERTY OR PDJ04NNG PROPERTY. D%Afro —G.j ._.... ; ...'.. . :. ................................. . . . . . ....'. . . ............ .:. :.. .. ..' r, ... ..4.. ..4... • - - _ .....:....y..............:.............�.... - - -- .. - - ..�........................................{.. . .. ...'. ;....'.....i......•......•y......:.... .. '. . ° ° .... .. .. .t. ir .. ... ... ......... .....v........................... • ..0..... .<.. .'...... .. ............. ..... .. .r .. .. 1 . . .I I: �.L 1 . . .Y. �LrN�� ENT.....:..... ... :....... .....:...... . .... ° ........... :..... = :... . . NAV .. 1.a i95.........:. ;.;.....a