Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PA, BOX 388, 304 EAST WEBER-AVENUE. STOCKTON, CA 9MI-388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED <br /> lComplete In Trlplfcstel <br /> APPLICATION!S HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WIT�IA SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITTLE,CHAPTER 8-1110.3 AND THE STANDARDS OF SAAN�JOAOUIN COUNT-Y PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR AFNIr:_ v ��j -j 1�7 � R"'r��1 CITY .ti. LOT SIZE <br /> � <br /> t" � 1.��� �'C f`�-Xa'1Q L� ADDRESS ONE <br /> :r'Y1��;i �� � - PHONE7 , <br /> OWNER'S NAME . <br /> CONTRACTORR, c��.--��i' t __ _ ADDRESS LPC• R710NE_ <br /> OUR CONTRACTOR ADDRESS LICE PHOM <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlADDITIOI lDE R�TIOJN ❑ <br /> [NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF RU DPNO.I �Y T P9SC TEST(%)I I NOW MANY <br /> �y Apolmdm 0 <br /> INSTALLATION WILL SETNE: RESIDENCE13COMMERCIAL.T< OTHER ❑ <br /> NUMSER OF LIVING WSi1TS; NU SER OF VEDROOMS': ` NUMBER +PLOYEES: <br /> CHAWICTER OF SOIL TO A DEPTH OF 3 FEET: PIT/BU 01 HARACTER: WATER TABLE DEPTH <br /> ■EPTIC TANKAMEASE TRAPL�TYPEMIFO APACITY C}L1 S�•? NO.COMPARTMENTS <br /> PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE. <br /> LIFT STATION 11 SIZE TYPE OF PUMP SAND OAL SEPARATOR 1ENCLOBEO 8YSTEMI <br /> LEAC04NO UNE L2( NO.A LENGTH OF LINES_ DISTANCE TO NEAREST:WELL - C FOUNDATION C d PROPERLY LINE ✓�f � 1 <br /> FILTER SFA ❑__WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST:WELL FOUNOAT!ON PROPERTY LINE <br /> MOUNDED CI MOTH LENGTH_ DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEEPAOE PITS ❑DEPTH 812E _NUMBER----T— <br /> DISTANCE TO NEAREST:WELL FOUNDATION P ARTY LINE <br /> SUMPS ❑WROTH—LEMYW�'�_DEPTH. g-- DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS ❑WIDTH LENGTHDEPT DISTANCE TO NEAREST:WELL r-OUNDATION PRO LI <br /> I HEREBY CERTIFY THA PREPARED THIS APPI-I AT N ANWfHAT THE WOR(WILL BE DONE IN ACCOR ANCE WITH SAN JOAQUIN COUNTY 4RDIN AND StATE LAW ,AND <br /> AND REOULATIONSOFTHE BAN JOAQUIN COUNTY.HOME OWNE ORUCL"SEDAGENT'SSIGNATURECERTIFIESTHEFOLLOWING:'ICERTIFYTHATINTHE PEWORMANCeOFTHE WORK FORWHICH r <br /> THIS PER mrr l6ISSUED, H L NOT EM Y ANY PER UCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTPACTOR`S HIRING OR n <br /> SUB-CONTRACTING 81 AT RE CERTIFIE E FO NG;'I C RFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WVOPKr.UW'8 COMPE T N LAWS OF r-0 A.' THE AP ANT Uil'CALL 24 X01848 IN ADVANCE FOR ALL REO.UIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> SIGNED X TITLE: r) <br /> DATE; r �` <br /> c-- <br /> f <br /> PLOT PLAN IDRAW TO SCALER SCALE m r- <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. i. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSION8 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURE�I, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. �! THE PROPERTY OR ADJOINING PROPERTY. <br /> c-1a `>J F <br /> �r � <br /> ��Ifr <br /> p:2lC <br /> .. <br /> . <br /> J R¢1ceA wt <br /> x ?r yc is 5 Y" <br /> �. <br /> AL 161997 <br /> cOUNI,r <br /> SA N <br /> .IOAIJu11v$ <br /> E <br /> S.Sfalf PU EAITti- RV1G <br /> j lC, EHV1R0 MENTAL HEALTH U1 SIOI� <br /> X. <br /> .. <br /> FOR DEPARTMENT USE ONLY UEjt <br /> APPLICATION ACCEPTED BY_ I '�-•C_� DATE: /I�(J[�------ <br /> PIT OR/SUMPINSPECTM4 BY DATE_,��F L INSPECTION BY SCJ/ C! 1(9p <br /> AMT30NAL COM✓✓lME14TS: r�— - t'L� /L- - - I re-- / o- <br /> Ie 4 I �i14LL r� <br /> � <br /> ACCOVN11N0 FACE AID/ FAc \ ' <br /> PE CODE FEE INFO AMOUNT RFMIWTED CHECKOICASH RECEIVED BY DATE SR I PEIIUTT NUMBER INVOICE I <br /> 19 <br /> Pub.Health Serv.•Enviro_174 ,(3186} �u 111& Ww�W rT �y4 — p `-� -0 -Ora, .�L t j f.✓firr�y <br /> h- -� l pye ,,W , old <br /> ��° 5 7 <br />