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1)016 ( z a , '''SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIr �y ENVIRONMENTAL HEALTH DIVISION ` f P,O, SOX 988, 904 EAST WEBER•AVENUE, STOCKTON, CA 95201.388 I X20 FILE C MON-REFUNDABLE PERMITIT E EXPIRESIBES 1 1 YEAR FROM DATE ISSUED i' (Complete In Triplicate) APPLICATION IS HEREBY MADE.TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCmBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN I JOAQUIN COUNTY bEVELOPMENT TITLE,CHAPTER 9.111 0.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. / ! JOBADDREBSIOR APN:r -7 SSS Uyyx G .CITY LOT SIZE _, I J a 1'/ �r �. �-� —- -- — I PHONE o OWNER'S NAME ADDRESS CONTRACTOR 1 L VW\ ,-_AODRESS LPC# PHONE r OUR CONTRACTOR ADDRESS LIC# PHONE 1 TYPE OF SEPTIC WORK: NEW INSTALLI9bN. REPAIRfADEMTtoR ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER ISAVAILABLE WITHIN 200 FEET OF BWLDING.1 PFRC TESTISI I I HOW MANY ApPllmdan INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL•JI(f OTHER❑ NUMBER OF UVLNG UFIITS: NUMBER OF BEDROOMS:-/ NUMBER OF EMPLOYEES: �� - CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT,,IS'U'M•P�COO,I,L CHARACTER: fh �.,y WATER TABLE DEPTH I SEPTIC TANKIGRFASE TRAP t3TYPEIMFQ �"� , �T.-_._CAPACrry /G- yV _NO.COMPARTMENTS PKa TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR{ENCLOSED SYSTEMI LEAC14NO LINE ❑ NO.&LENGTH OF LINES !" DISTANCE TO NEAREST:WELLS, _FOUNDATION PROPERTY LINE r FILTER BEP WIDTH �I LENGTH KO! DEPTH VL DISTANCE TO NEAREST:WELL I _FOUNDATION, r'(] PROPERTY UNE ` MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH SIZE � NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMP$ EI WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE i DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ry, 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AQENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFYTHAT INTHE PERFORMANCE OFTHEWORK FORWHtCH THIS PERMIT IS 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 SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WNOWMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RECUIRm INSPECTION$. COMPLETE DRAWING BELOW. 7 S !3lGNED TITL.E:�/� - DATE: I7lc2AI �/ �- F PLOT PLAN(DRAW TO SCALE)SCALE '10 I 1. NAMES OF STREET73 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED S 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, v J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON b INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS,AND WALKS THE PROPERTY OR ADJOINING PROPERTY. ...,... ... .... . .... .. ... ... :.. L... ..1..... ., .. ., .. .. ., P kk .. r ...,... .. .... .... ..... .......... ........... ...... f .. .. .. ........ .. ....... ...... ........... ......:...... ....... ............ .......... ........ ........... ....... :.. '► _ I .. . DEC 2 4 1997.. QW11 i�GuI k3 - . - RN JUA PU$LIG I:�F,.,QLTIi.x�ra E[V1(11�ONWNTA NFAL wt�]n.rlt,l4�l: .. ..., :. . ... . . ....., .: ....:...... 1 �,.FOROEPARTMENT-USE ONLY".......,..r�+..d� 017 APPLICATION ACCEPT!Oe ~` bA+ t DATE: / AREA: f7 OR SUMP INSPECTION BY DATE I 1 FINAL INSPECTION BY 1 DATE ! -r AD TIO L COMMENTS; 1 you I ACCOUNTING ONLY': AID# FAC# i PE CODE FEE LNFO AMOUNT REMI ITED CHECK#!CASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE# T - G d 5 39 D lo9�f Pub.Health Serv.-Enviro.174(3196) mill woy"n Tr-"-"