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• APPLICATION FOR LfOUIG yTE PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> l�BLUE ff (PIAES YEAR ng RATE R9UE0 <br /> (AMpktD M TrtpR66td <br /> ■}CATION H FIERY MADE 7 411 JOAOIAN Covent'FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL TNM WORK OMFOICED,THIS Apl`UCATION 16 MADE IN COMRIANCE WON BAN <br /> AUM COUNTY OEVELOPMEM t,CHAPTER B•111 Id AND THE/cr ZARG6 OF RAN JOAOUIN COUNTY PUBUC HEALTH SERVICES.ENVIRIONMENIAL HEALTH DIVISION. <br /> JOS ADGREsaA]R APR/ E � ti�- '��•� ,ybdk �' '��� � e� r�'G y LOT R1ZE <br /> G <br /> OWNER'S NAME ADDRESS PHONE <br /> CONTRACTOR ADDR¢SS )JCS PONT <br /> SUSCOHTRACTOR ADORE )ICF PHONF <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REVAWIAODItION tJ DESTRUCTION❑ <br /> IND SEPTIC OMEIS PERMITTED IF PUeUC SEWER IS AVARAw WfrHIN TOO FEET OF BUROINO.I PBW TEST1.1 I I HOW MANY <br /> APPBeaS-F <br /> INSTALLATION WILL SOME! RESIDENCE❑ COMMERCIAL❑ OTHER❑ ' <br /> S NUMBER OF LANG UMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYFEI: <br /> CHARACTER DF SOIL TO A DEPTH OF 7 FEET: PTMMP SOIL CHARACTERT WATER TABLE DEPTH <br /> SfPRC TANKIORKA29 TRAP 0TYPEmrO CAPACITY NO.COMPARTMENTS <br /> PKO TREATMENT PUINT 0 016TANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br /> )RPT STATION 0 SIZE TYPE OF PUMP BAND OIL SEPARATOR)ENCLOSED SYSTEM) <br /> LEACHING UNE ❑ NO.a LENGTH OF LWFR DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> FRTI 10LTJ (3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST-,WELL FOUNDATION PROPERTY UNE <br /> MOUNPED ❑WDTH LINDEN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SEIPAGE RTl ❑DEPTH S¢E HUMBER DISTANCE TO NEAREST:WELL FOUNDATION PrownrY Lim <br /> DUMP) ❑WITTH LENITH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTYLINE <br /> k 1 HERESY CE F'Y THAT 1 HAVE PHEPARIED THIS ATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES Aro STATE LAWS,AND Rue <br /> HEREBY THE BAN PMT." HOME GARNER ORLICENBED AGENT'S SIONATVRE CEItTIFlEB THE FOLLOWING:ryCE1TTIFYTHATIRTHEPERFOPMANCEOFT-WORLFORWIIICH <br /> TInR PER.ITT O S NOT EMPLOY PERSON M SUCH A MANNER A6 TO MOGME SUBJECT TO NARLMAN'R COMPENSATION LAWS OF CALIFORNIA.'CONTMCTOq'9 HDSN6 OR <br /> 8V&CO }IO SIONA CERTIFIES THE OWING:'I CERTIFY THAT IN THE PE/6ORMANCE OF THE WOW FOR WHICH TWO PERMIT IS ISSUED.I RHALL EMPLOY PER90NO SUIUECT TO <br /> wGIKMAN'S T OFC THE APPUC T MUS Y CALL M HOLSB IN ADVANCE FOR ALLL RRIPBUI LED INSFIVOTIONI.COMPLETE OFALMNG BELOW <br /> SIGNED% <br /> +'I��-TRLE: T DATE' , <br /> PWT RAL DRAW TO SCALE)SCALE <br /> 1.NAMES OF RIRETTS OR RIO 6 TO OR BOUNDING TOE PROPERTY. 104.LOCATION OF HOUSE WWAOE CHIPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND HOILTH OrECTION. EXPANSION OF SEWAGE DISPOSAL SYSFEMB. <br /> O. DIMENSIONED OUTUNE6 AND LOCATION OF ALL EXISTING UR <br /> AND PROPOSED STRUCTURES, 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTV OR AOJORANG PROPERY. <br /> a A) ` ~ <br /> ..� <br /> ... .. <br /> ... �� Csr <br /> J.. <br /> .... <br /> ..... <br /> ........... . . <br /> �.. <br /> ......... <br /> .... ... <br /> ............ 4: <br /> PAYMEN F;... <br /> .. ...... <br /> 1 : <br /> .. .e.... <br /> All <br /> .. .-.- .... L.. .. ---. <br /> .....'..PUBUC.HEALF -SERV S '- <br /> ENVIRQNMENTRL HEALTH OGVIS�QN „ <br /> ED DEPARTMENT USE ONLY <br /> AREA: <br /> APPLICATION ACCEPTED BY A A '"�',__ ^ _DATE' E' • -- <br /> TANK.PTT OR SUMP INSPECTION BY DATE ! I FINAL INSPECTION BY DATE 1 1 _ <br /> ADDITIONAL COMMENTS- <br /> FlF-MCOUNTTNO ONLY: AMR - FRS <br /> PE COPE FEE INFO AMOVNT"WAITED Ian ASH RECEIVED By DATE SR 1 M30W NUUSEL INVOICE E <br /> Lb z <br /> Pub.HRaBh Serv.-EnWo.174(7186) <br />