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=� APPLICATION FOR LIf1U10 PERMIT SAN JOAQUIN COUNTY PUBL..�HEALTH SERVICES cENVIRONMENTAL HEALTH DIVISION U�-'�C� `� 304 EAST WEBER AVENUE,STOCKTON,CA 9520 ON Z09-190-i�, (209)468-3420 gulC.UiiSra PiEkmcr NON•RFFUNDABIE PERYNT PINES 1 YEAR FROM OA SSNED q�a�78 1 MompI{18 In TTiplWool APPLICATION IS HEREBY MADE TO THE SAN JGAGUM COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MPIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 0-1110.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADOAESamRAPNE 0 yy i O (Crl'IIR�G►{� errY �QACY _-LOT SIZE ONMER'B NAME '}CAU T�RCNA __ ADDRESS sACIZAM;1 : Tt7 P110NE(%0727`�q E'RLCIcµ � 4 `= 2c5 4E BSNTMCTPIR DIAL P_ 1 - �L.1^?'tS ADDRESS LICE PID GUS CONTRACTOR ADOREBB LIC/ PHONE TYPE OF SEP M WOR![: NEW INSTALLATION Q MMI UUADINT30M❑ DESTRUCTION SIO SEPTIC SYSTEM PERMITTED 1F PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PER.TESTI.I4HOW MANY I i- caLA-P0P TM�-f- APPI-d R S INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL fl OTHER Q NURSER OF LIVING UMTS: NUMBER OF SEDNOOM{; NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF FEET: PrrMUMP SQrL CHARACTER: WATER TABLE DEPTH SEPTIC TANNIO SASE TRAP ❑TVPFIMFO CAPACITY NO.COMPARTMENTS PKO TREATmwT RANT CI DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF RUMP SAND OR SEPARATOR IENCLOSEO SYSTEMI LEACHING:LINE 0 NO.•LENGTH OF LINES DISTANCE TO HEAREET:WELL rOUNDATION PROPERTY LINE FILTER RED Q WIDTH . LENGTH DEPTH INSTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE (MOUNDED Q WrDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LME SEWAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SUMPS [3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PIOP'ERTV UNE DISPOSAL PONDS ❑WIDTH UHQTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION RROIERrV UNE I HEREBY CERTrPY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND MULES AND REOVLATIONB OF7ILE SAN JOAOUM COUNTY.HOME DWNEN OR LICENSED AGENTr@ WGNATURE CERTIFIE{THE FOLLOWING:'ICERTIFYTHAT MTHE PV"IVEANCE PFTNEWDRK FonwNxN THIS PERMIT IS ISSUED.I RHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WCLKMAWS COMPENSATION LAWS OF CALRARNIA.'CONTRACTOR'S NSSIIO OR SUB-CONTRACTMO SIGNATURE CERTIFIES THE FOLLOWING:T CERTIFY THAT M THE PEmPORMANCE OF THE WORK FOR WHICH THIS q"Arr IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAMS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGURm III{PEWWKS.COMPETE DRAWING BELOW. !' STONED K ✓T�1TdJ�J�I J/IIIA J l�Tom/n, Tr1LF: ly l l_ 1�! DATE: " 7.- U PAT PLAN IDMW TO SCALEI SCALE 'le T,NAMES OF STREETS 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. EXPANSION OF BEWARE DISPOSAL SYSTEMS. r J.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. B.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON C INCLUDING COVERED MEAD SUCH AS PATIOG,DRIVEWAYS.AND WALKS. - THE PROPERTY OR ADJOINING PROPERTY. \R ...... .. --., .. ... .... c .. x . .. _... ... .. . a. .... :. .... :. }� tp� Asks t PAYMEN .. ... w.vv ... FEB 1219 9 : ' lk }�. : ..: .: .. .... QU{N UICF ..... ... ._- .. .. .,..;. - - Ei SAN JO PU13LICH ..... ............... FOR DEPARTMFJIT U{E ONLY / APPLICATION ACCFPrED BY DATE: —J AREA: QG l PANIC,PIT OA SUMP INSPECT{I'ONr Y ! PATE I --L_FINAL INSPECTION B PATE 2 ADDITIONAL COMMENTS`/H ��1 41. !I�q.�'�S% �7 A&y ACCOUNTING ONLY: AIDE PAGE I DECODE Q1NFO AMOVNT RHYSITEO AASH RECEVEL BY DATE {III PH".NUIPSER. INVOICE/ 3 V 3 ii f Pub.Haan Serv.•ErmrD.174(3195)