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SA OUIN COUNTY PUBLIC HEALTH SERVICES WRONMENTAL HEALTH DIVISION P-O,BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 (209)468.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IC{ml In Tripll{ftf) APPLICATION IB HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR A//P11NE_ CA to ';'I S'r" �I P7 1 OWNER'S NAME _i�f} `<n I A"'�-�I ADORE 8 5 �� GIN r\p, Pp n LOT SZE�� CONTRACTOR1'I6-- � FL/I[[ _ADDRESS �F//�Q F7Ok �- L LIC{ �RIONE 9 7?T3 SLID CONiMCTOR ADDRESS UCI PHONE TYPE OF fF1TIC WORT(; NEW INSTALLATION❑ REPAIR/ADDITION OFITRVt TION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDING! PFRC TU71H 1 1 NOW MANY APPnoatlan F INSTALLATION WILL{FAV E: RESIDENCE l COMMERCIAL❑ OTHER❑ NUMBER OF LANG UNITS:_NUMBER OF BEDROOMS: _NUMSER OF EMPLOYEE{: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: 4 c PITISUMP BOIL CHARACTER: �L� Y.�,^1� WATER TABLE DEPTH SEPTIC TANIUg1EA{E TRAP {a TYPE/MFO tl CAPACITY v ` Aa 0 n� NO.COMPARTMENTS MO TREATMENT PLANT❑ DISTANCE TO NEAREST; WELL -':;-H FOUNDATION 10 PflO PERTY UNE�'� UFT STATION❑ 612E TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE NO,S LENGTH OF LINED_ II�� • R 1 r-1 YE7 DISTANCE TO NEAREST:WELL sn I FOUNDATION 40 PROPERTY LINE JOI FILTER BED ❑MOTH LENGTH DEPTH - DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED 11 MOTH LENGTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE FITS �❑1DWIDEPTH SIZE NUMSER_DISTANCE TO NEAREST:WELL FOUNDATION_PROIR Y LINE SUMPS tl DTH �.LENOT�DEPTH DISTANCE TO NEAREST:WELL le in/ FOUNDATIONPROPERTY UNE�— DISPOSAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PRO{•ERTY UNf I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE MTN SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAGLIN COUNTY,HOME O WNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 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 BUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(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 MEGLXAED N{PEC7ION{.COMPLETE DRAWING BELOW. BIOMED% � .(�� TITLE: DATE: PLOT PLAN[DRAW TO SCALE)SCALE.-IP /. NAMES OF STREETS OR ROAD$NEAREST TO OR BOUNDING THE PROPERTY. 4. S.OUTLINE OF THE PROPERTY,MTN DIMENSIONS AND NORTH DIRECTION, LOCATION OF HOUSE IFWA SEWAGE AL SYSTEMS.SYSTEM OR PROPOSED 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, EXPANSION F SEWAGE DISPOSAL SYSTEMS. INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION Of WELLS WITHIN RADIUS OF ONE HUMORED FIFTY FT.ON THE PROPERTY OR ADJOINING PROPERTY. WITS+ RJP�n Q P d 1 or_ 'qy AUG 4 1998 LY 'PLICATION ACCEPTED BY \ R NMENTAL HEA�IF'ICCs FOR DEPARTMENT USE ONLY ENVI NEA, Y DATE: PL(XlSlp/ CNK,PIT OR BUMP INBPEC71014 BY DATE // FINAL INSPECTION BY DATE_____ -01710NAL COMMENTS: ACCOUNTING ONLY: AID0 FAC. PE CODE FEE INFO AMOUNT REMII TED IIE CASH RECDVEO SY _ DATE M/PERMIT NUMBER INVOICE I Z 85 Pub.Health SaN,-Enwo.174(3/96)