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SA 'AOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ""ENVIRONMENTAL HEALTH DIVISION as <br /> P.O. BOX 388, SIX EAST WEBER•AVENUE, STOCKTON, CA 95201-388 0 I <br /> (2091468-3420 <br /> NON-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 19 MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN/ C�'/1�C1 O ��wlJ 9�(�f�Qyy[��'0, C- �� ,� , C-Iifyq wCr'Y C��Ikv"O LOT <br /> 181ZE��[�["]-� <br /> OWNER'S NAME��,jMPd1r1L>;yj��FT\l�Jfl�.�11� lv gDDRE86 �-�yQ(�(jQ �!:)40 J�t��7F�'C t(y,J n�' ,y'',{,PHONE �'J`/—CAFC3 <br /> CONTRACTOR- r te) C..1��1.iti"�w�•�� I��. ADDRESS `'T'�J /� LICI Irak- PHONE I�LJ w <br /> SUB CONTRACTOR ADDRESS UC# PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIMADDITION ❑ DESTRUCTION ❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TESTM`I�I HOW MANY <br /> APpll—d— <br /> INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF WINO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> CHARACTER OF BOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANK/OREASE TRAP ❑TYPE/MFG CAPACITY NO.COMPARTMENTS <br /> PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> LIFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR(ENCLOSED SYSTEMI <br /> LEACHING LINE ❑ NO.a LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE PITS 13DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> {LIMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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:'1 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 WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> 1{ <br /> SIGNED X� �- ^� TITLE: Vl DATE:_ L+I `—Icf�`t <br /> PLOT PLAN(DRAW TO SCALE)SCALE 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, 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 /> ... <br /> p._..:.....:. ...: <br /> .............. .. <br /> _..........-i.............i...... <br /> ............ i............. .. .. .. .. .. .. .. .. <br /> ..:..... <br /> '......:.. ........:........ <br /> ...........:....................:......:.............:...... .. .. .. .. .. <br /> ........:..............:.............................................. <br /> .....................................:...... .............'.. <br /> .:. :.....:... . <br /> .....:.......................... <br /> ......:......:...... <br /> .::......:...... <br /> ......:.............:..................... .. .. .. .. <br /> ...... ..........,.............,.......:....................................,.......:......;.......�......�... <br /> .............:......;.......:.............:......:.......:.............:......�..............;. .. <br /> ...:.....; <br /> _....i..............i......:.......................° ..° i <br /> .............:......:.......:......`.......�.....;.............:... <br /> .......:.. ... <br /> :..................:.......;.................................;:........... .. . <br /> .................... ................. ........................................... <br /> . : .. .:.....n...........<..... .. .. .....`......... .. <br /> ...;.. ..:... <br /> ........... <br /> .............................:............: ._.......:_ .....:....... .. .. .. . . . <br /> ... ..:.....;......:... <br /> F.E <br /> D :1999 <br /> rest <br /> ...... . .. .. ....... ......... :............ ... .. . .. <br /> .................... _ ......:......;..... <br /> ;.. <br /> ii';i�ipa i OUNI'Y....: <br /> ................... .. <br /> ;................. .....;..... .. .. T <br /> .... <br /> ... <br /> 'S f <br /> ..F'.UpL1G HEAL SERVICES <br /> �N1�IHC)lvtdENTgL 1`�ALLH AiY.I, <br /> FOR DEPARTMENT USE ONLY u <br /> APPLICATION ACCEPTED BY DATE:—z'/1 AREA: z. f <br /> TANK,PIT OR SUMP INSPECTION BY J / U DATE / / FINAL INSPECTION•9 III - G• *DA7E <br /> ADDITIONAL COMMENTS:_y-� J'j L�l'�S DV�t(i,-tp�'l� <br /> - %5P� — e� 1 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE FEE INFO AMOUNT RMNITED CHEC CASH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE# <br /> Z �SSD3 l� �lq 9 <br /> Pub.Health SerV.-Enviro.174(3/96) <br />