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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `3 . ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER MENUE, STOCKTON, CA 95201388 12091489-3420 NDR-REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED (Complete In NpUeetel 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 HATH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11111'0.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDREBSIOR APNM_ [ ` � � � �C iii CITY �C -'.a�� LOT SITE �^ I _ l!r,, I� ray OWNER'S MAME_��Al A^.0 Yuc_Z ADDRESS •• �// ^� Pl10NE �J�Cr)`- /�0 CONTRACTOR C J� Q IL'U Y'L J{� �GADDRESS l z/ Al,-,// S L LIC/ �C PHOHE�CP ] J �%3 SUB CONTRACTOR ADDRESS UC/ PHOW'. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION ❑ IND SEPTIC SYSTEM PERMrrfFD IF PUBIJC SEWER IS AVAILABLE WITHIN 200 FEET OF BUIL ING3 PERC TEST[G)[ I HOW MANY Applloetlan F INSTALLATION WILL SERVE RESIDENCEV COMMERCIAL ❑ OTHER ❑ NUMBER OF WINO UMTS: NW49ER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF BOIL TO A DEPTH OF 0 FEET 7lSUMP SOIL CHARACTER:�l'P'IGry Lt.-WATER TABLE DEPTHQ " SEPTIC TANKNIREASE TRAP ❑TYPEIMFO CAPACITY NO-COMPARTMENT3 PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION 11�S,12E TYPE OF PUM/P� SAND OIL SEPARATOR IENCLOSEn SYSTEM) LEACHING LINE JI] NO,&LE (Fit LENGTH OF LINES_�-7G r e DISTANCE TO NEAREST:WELL R-0 r� FOUNOATK)N��PROPERTY LINE FILTER BED ( ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH ^7 LFNOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEWAGE RTS DEPTH ZS SIZE -2 Gv NUMBS DISTANCE TO NEAREST:WELL C9C� �F-0UNJAT14N #PROPERTY LIRE.-� R SUMPS ❑WIDTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE D18MRAt PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HERBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES ANDRGULATKINBOF THEBAN JOAGUINCOUNTY.HOME OWN OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;•I CERTIFY THAT IN THE PERFORMANCE OF THEWOFKFORWHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN UCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUI SIGN CERT E O HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORK AMS COM N TION WS CALIFO I THE P ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INePBCT1ONS- COMPLETE DRAWING BELOW. SIGNI x TITLE; , ` a DATE: • PLOT PLAN(DRAW TO SCALE)SCALE _•Ie 1. NAMES OF S RESTS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EAPANSroN OF SEWAGE DISPOSAL SYSTEMS. i 9. 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. L L. �,t v .. .. v ... .. . _ . .. ., ". _ . I :, -.... . .,..,, x ... ......, aa ......,....., : . ti3 ' . . �... 9 .. ... .......... �. , . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ DATE- AREA: TANK,PIT OR SUMP INSPECTION BY DATE I /1 FINAL INSPECTION BY S AYE 12e1 ADDITIONAL COMMENTS: t( !7 7rJ .__L_r..5 ?c mac{ \-'��rel lin-: ;;; - frLi rl b-0 5-K(�{ /I S` ( -C Z, ACCOUNTING ONLY: AIDE FAC0 PE CODE FEE INFO AMOUNT RFMI I TED CASH RECEIVED 9V DATE SR 1 PERMIT NUMBS( INVOI E 0 Z 1 0�g3 _ ,4111q& S.? 7 rf Pub,HeaHh Serv.-Enviro.174(3196) t