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VC41(e� •`` S"' JOAOUIN COUNTY PUBLIC HEALTH SERVICES -s cam \./ ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988,304 EAST VVEBEWAVENUE, STOCKTON, CA SIMM- 08 (209) 4983420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED )Complete in Triplicate) APPLICATION N HEREBY MADE TO THE SAN JOACURNI COUNTY FOR A PERMIT TO CONTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLIOATIUN 18 MADE IN COMPLIANCE WITH SAN JOADUIN COUNTY DEVELOPMENT TZAITLEL C�PIAFTTE�R 9.1110.3,AM THE ST AMR OF AN JOAOUIN COUNTY RIBUC HEALTH SERVICES.ENNIgNMETAL HEALTH DIVISIMN. p�1 �/ L JOB ADDRESS/OR AFNS `V fJ -/n s: HC44 4 LSA 1�1nT /(] CITY .J�� 1 LOUT WAzjR ( J� v OVJNEA'S NAME CVI.-k 7 .LV\C. ADDRESS_ .1J0 '�1 I7V I7(. Lo 15C.('CYCA.IMY_N IO Row 53 - O 77^�'1� CONTRACTOR S ADDRESS t 000 ' `L �l �SCJ Lx CLI( LIC) oS l RIONE � 1 BUR CONTRACTOR ADDRESS me PHONE TYPE Of SEPTIC WORK: NEW INSTALLATION lbq REPAIRIADDIT10N ❑ DESTRUCTION ❑ IND RETIC SYSTEM PERMITTED If PUBLIC SEWER IB AVAHARLE WITHIN 200 FEET OF BUILDING.) MC TESTNI 1 1 HOW MANY APPRl don f INSTALLATION WILL STRIVE: RESIDENCE❑ COMMERCIALS OTHER ❑ ../I 1_ 1 jail BER OF NG UNITS:- NWSER BER 30 CHARACTER OF^SOIL TO A DETH OF O FEET: OF BA L/L�&A;t FD/SUMP SGIL CHARACTER:OY� WATER/TABlFy!P/�H � ` w`/J`�OO SEPTIC TANK/OREASE TRAP *0TYPE/MW �� -J��'��111��.��, CAPACITY �yOO NO.COMPARTMENTS WO TREATMENT PUT❑ DISTANCE TO NEAREST: WELL US FOUNDATION_ PRGFERTY 1IPT STATION❑•RSEIZE TYPE OF/J`'jU P SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE C''♦M.A LENGTH OF LINES \J✓ J O(� DISTANCE TO NEAREST:WELL FOUNDATION /0 P110PERTY UNE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DELL IO FTH DISTANCE TO NEAREST:WEFOUNDATN PROPERTY LINE EE SPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE BUMPS 11 MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL IONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WE11 FOUNDATION PROPERry LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN"AWN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SMI"AW IN COUNTY.HOME OWNERORLKENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'ICETIFYTNAT LATHE PERFORMANCE OF THE WORK FORNMICH THIS PERMIT IS ISSUED,IIBBHALL NOT EMPLOY AT PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRNO OR SUB-CONTRACT NG WING�'I CERTIFY THAT N THE E OF THE WORKMAN'S COIMPEN ILTIOI LA//'WS OF CALIFORNIALo H�ET/�AFPL1CA T MUST CALL 24 HOURS INCADVANCE FOR ALLREQUIREDINSPECTION&ISSUED, COMPLETEHDMWINO BELOW. PERSONS /ySUBJECT TO SIGNED X V �' W– 1 TITLE: CFO DATE: PLOT PLAN(DRAW TO SCALE)SCALE 'W 1. 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 SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON MILLUyDIN�G COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND/WALKS. THE PROPERTY OR ADJOINING PROPETY. CL ��tr V-�LP6 (�CL)V CJ � res r .l 4� (0 ^` L1WI. \J s L u I � y f, _ S~ _ �I4A N'. Ku et� TYL��L � Q CtvV , 5 CCWv\ w,uv\',' � � CJ�j( ucciF-ecQ Civ. vert FEB 25 1999 - SAN JOAQUIN G(A eN YUI3UG HEAL1 H SkH`JlCES .. ENT WE ONLY APPLICATION ACCEPTED BY �_PL/1/y v, L.T L�i/I/ DATE: I I AREA: �l Y/ TANK,RT OR SUMP INSPECTION By/ ppp DATE / / FINAL INSPECTION BY DATE ADDITIONAL COMMENTS:�2 NJ�1 1 5 Y'S TFN'1 1` 9 ACCOUNTING ONLY: AIDS FACS PF CODE FEF.INTO I AMOUNTREMNTED I(-CNECK RECEIVED BY DATE M/PERMIT NUMBER INVOICE �1 SCi 2-50100 Pub.Health SeN.-Enviro.174(3/96)