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SAN QUIN COUNTY PUBLIC HEALTH SERVICES <br /> _AVIRONMENTAL HEALTH DIVISION cco5v <br /> P,O, BOX 388, 304 EAST WEBERAVENUE, STOCKTON, CA 95201388 <br /> (209) 468.3420 <br /> NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER <br /> C/H�APTERR 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. '57-1,153 X <br /> JOB ADDnESS/OR APN# L7V v r`��S 1 (�L�/�N �Y 'LD' "y� LOT SIZE+ 7iG Y <br /> OWNER'S NAME �1' �y, FOOD ADDRESS �1�LS` �1 � -j 01 t* 1`- D' {� <br /> PHONE n / J <br /> CONTRACTOR ML�ONr'�L3� SV1�l"•�) ADDRESS q6,4(; WiI�ICfk�7Lry, LIC# 77 '5q✓ PHONE")-51-0`lq t <br /> SUB CONTRACTOR ADDRESS I!`-N� l/F\ 13 Z"`i '4' LIC# <br /> PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ® DEa TRUCTION ❑ <br /> (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PFRC TESTW I 1 HOW MANY <br /> Appli-flon J <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ® OTHER ❑ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:p� � •-7 <br /> CHARACTER OF SOIL TO A DEPTH OF 3 FEET: SR WD PIT/SUMP SOIL CHARACTER: �Jf"y t WATER TABLE DEPTH /O <br /> SEPTIC TANK/OREASE TRAP �TVP'E/MFO ExLST 1 N ,I L. Y �t�APACITY ( O LZ 1,��� NO.COMPARTMENTS <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP f SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> PITY LINE 'Se) <br /> LEACHING UNE � NO.6 LENGTH OF LINES Z 1- U U , DISTANCE TO NEAREST:WELL FOUNDATION 100 PROPE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I 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 <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 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 <br /> SUB-CONTRACTING 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 <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR(ALLLRREGUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> SIGNED X �`� ��"'`-'' TITLEN �.XJ�1 L�/1�� 1" `�``�F- DATE: <br /> PLOT PLAN(DRAW TO SCALE)SCALE ' ' t <br /> 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. EMS. <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF WELLS WITHIN RADIUS EXPANSION OF SEWAGE DISPOSAL SYSTT ONE HUNDRED FIFTY FT.ON <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, THE PROPERTY OR ADJOINING PROPERTY. <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. <br /> ..;......i.......... i..... .. .. .. <br /> i .......;.......i...,. .. .. .. .. .. .. <br /> ... ...:...........:...................... .... ...... . <br /> i <br /> ......:..........................•.....:.... .. .. ........ - <br /> ...:.. ...:..... <br /> . _ . ..1 00 <br /> P L <br /> ii <br /> Y ► - <br /> .................... <br /> �off` �>✓-p-�� t%1 N .............. <br /> ........... ......... .... :... +...... <br /> .. .............................. .. .. ¢� <br /> :.. <br /> .. <br /> _ ...... .................. ............ .......;..... ...... ...........toz� . .... ...........<.............................................. .. �j <br /> .......:......<...................... <br /> .:.....<......:.......;.. .. <br /> ..................... .. .. .. <br /> ......;.. ... <br /> .:.....<... ..:.. ..<..... <br /> :......:.. .. <br /> .. . <br /> ......:.......:.......... _ <br /> .... <br /> . ...... .......... . <br /> .. <br /> .:.....:... <br /> .....;......: <br /> j............ ... J.`_ <br /> ........ <br /> �A <br /> 3 <br /> ..........MAR -12 1999 <br /> ......... <br /> 11 <br /> �Ah J J�k Iain L <br /> __ <br /> ED \'L�\ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED <br /> GK DATE: J I v AREA�� <br /> DATE <br /> DATE / ! FINAL INSPECTION BY ! <br /> TANK,RT OR SUMP INSPECTIO BV ,.1 ,I/ <br /> ADDITIONAL COMMENTS: -f'' L �_( _ITT /es (o, ,v <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE FEE INFO AMOUNT REMIITED CHECK# .ASH RECEIVED BY DATE SR/PERMIT NUINBER INVOICE# <br /> G/Z/S O ZSrJlDlo1 3113IqIL <br /> Pub.Health Serv.-Enviro.174(3/96) <br /> a-0 I l`( <br /> A 64 <br /> � L�V­j D r✓ <br />