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SAF! JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION Ro. BOX 388, 304 EAST WEBER-AVENUE, STOCKTON, CA 95201388 -A0 �. � Do (209f 468-3420 ,. 11011•REFUNBASLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �r I�ckt� (Complete iR Tripliests) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN OAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AN THE STANDARDS OF S N IOAGUIN COUNTY PUBLIC HEALTH SERVI S,EERRONMENTAL HEALTH DI'JISION. OB ADDRESSOR APN4 CU / C`f/T�/ R LOT S12E �I OWNER'S NAME ADOR ( ` t�l/"t.A PI10NE :ONTRACTOR MURESS ^ LIC, PFiONE��79z�1 SUB CONTRACTOR ADDRESS LIC! PHONE "YPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION❑ NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTM[ 1 HOW MANY �[/ Appli–d n l E INSTALLATION WILL SERVRESIDENCF7IJ CO6iMERCIAL❑ OTHER❑ (UMBER OF(MNG UNITS: NUMB13t OF BEDROOMS: NUMBER OF EMPLOYEES: :HARACTER OF SOIL TO A DEPTH OFT--3I FEET: �� PIT/SUMP SOIL CHARACTER: �1^ WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP L?'f YPtIMFO L-C CAPACITY 1�2 0 0 NO,COMPARTMENTS MCO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) ` LEACHING LINE ©ANO-&LENGTH OF LINEf�Z j �Q DISTANCE TO NEAREST:WELL -- FOUNDATION /�' PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE AOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE n n CEEPAGE PITS �.{ !STANCE 70 NEAREST:WELL/GO F-OUNDATroN �O / PROPERTY LINE SUMPS 1L WIDTH LENGTH 0_DEPTH_DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 'NSPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTTIFYTHAT IN THE PERFORMANCE OF THE WOR:FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. }9 SIGNED X 7t—) TITLE: DATE: PLO (DRAW TO SCALE)SCALE 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUND( G 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, 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREASSUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. C3� - . .. . ...... . _ .. .. ..:......:. ..:......: . . ..:... :-. r ',V" 8b lot. ........:......:...-.:.......-. . ........... .;. .. a Q ...... .... ...........;... LC.� v \' (�c[� J F1G1 PUdUQ HrALT 1 SE{1VICE'� ,.. ;• � r ENVIRONMENTAL HEALTH I?tVfSIGh' . u- 2- ')-X,)() x 1Z0 ... ..........._ .......... ...