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JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95MI-M 12991469-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (C4mpl4to in Tripli-tS) 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 COMPUANCE WITH SAN ' JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1110.3 AND THE STAND DS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVUIUNMENTAL HEALTH DIVISION, NI 1 JOB ADDRESS/OR APq y, (il 1 L ( c'Q.c---, CITY f�),�Cwt LOT BRE OWNER'S NAME \I�L A.\\\/\`l'- \I V�T+ t ADDRESS �G.�t r,' ( J /- PHONE 3c, CONTRACTOR_ CI.V'V\SInI/TORS' ADDRESS yODO N, `'JI (50tA tJCF (/OO�J�I PHONE SUB CONTRACTOR ` ADDRESS UC1 PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADOITION DESTRUCTION❑ tf� IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF SUILDING.I ' PMC TFATI.)l I HOW MANY APPlloatlae i INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL[3-2 OTHER❑ NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES:,, CHARACTER OF SOIL TO A DEPTH OF 3 FEET: %t WT/SUMP SOIL CHARACTER:-31 CL Vl WATER TABLE DEPTH ^V SEPTIC TANK/OREASE TRAP ❑TYPE/MFG CAPACRV NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP ,y SAND OIL SEPARATOR(ENCLOSED SYSTEM) LL ( 1 LEACHING UNE NO.&LENGTH OF LINES l.F. `Oy DISTANCE TO NEAREST:WELLC, T POUNDATION_j PROPERLY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE y, SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE ,v SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE p� DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARE.THIS APPLICATK)N AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATION:OF THE GAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 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 SUB-CONTRACTING-SIGN#,TURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSAtIO�N/LA�WS OF CAUFORNI4/r(THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED%�1 1 L�I TITLE: DATE: �L b PLOT PLAN(DRAW TO SCALE)SCALE 'le 0- 1. 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF TILE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. f D l' J i ^� 7 c... .... 11 W-I _ U k _ N 2-5:1998 FOR DEPARTMENT USE ONLY SAN JOAQUIN COUNTY PUBLIC HIC E VICES APPLICATION ACCEPTED BY _ F _ -- DATE: E VIROtYE NTAIrFi L CI SION TANK,PIT OR SUMP INSPECTION BY �(� DATE I I FINAL INSPECTION BY (. DATE 30, ADDITIONAL COMMENTS: ��r•��/HT6t'��L.l.� �� '��7( �.IN &—3Z>48^ 4-k 1E6' C�A—'/V W IAS 6 F, OK ffCODf NLY: AID1 FACS —� FEE INFO AMOUNT HEJIIIIED CHEC /CASH RECEIVED BY DATE SR/PERMIT HTIMBER 2HVOICEV l d (o 0177 Pub.Health Serv.-Enviro.174(3/96)