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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468-3410 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplieata) LICATION 18 HEREBY MADE 10 THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAN ,QUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF RAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ADDRESS/On APNI LA t� (0 S t l�'Sr1t-S'tQ:y,l C CITY �F'1 C�i LOT SIZE` HER'S NAME_ L(i(�r 7 J-0 k. L 1 ISA 6X[Y-(� ADDnePHONE i TRACTOR ADDRESS 7`hS Lg.'1� fn_(-(� UCI 3 5t4 PHONE ,�)-7 773 'CONTRACTOR ADDRESS UCI PHONE E OF SEPTIC WOnK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION ❑ SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDING.1 PERC TESTW 1 1 HOW MANY APPRowHen I TAI LATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER ❑ _ JIBES OF LIVING UNITS:— NUMBER OF REDROOMa• 3 NUMBER OF EMPLOYEES: �n \nACTFn OF SOIL TO A DEPT11 Or--3 rEFT:��Yj-C- PIT/SUMP SOIL CHARACTEn: S•'-ICs' WATER TABLE DFPTII TIC TANK/ORE'ASE TRAP iT--LQTYPE/MFO CAPACITY NO.COMPART MENT9 JIL TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL l 17:1 I FOUNDATION I�] / PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) AVL CHINO UNE CJ NO.6 IENGTH OF LINES + DISTANCE TO NEAREST:WELL I<-)Q FOUNDATION ��RROPERTY UNE (� ER RED ❑WIDTH LFNGT14 DEPTH_ DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE I JNDED �❑WIDTH \_LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE L �` PAGE Ria p DEPTH .-}j SIZE -�{�.t I NUMBER_J DISTANCE TO NEAREST:WELL FOUNDATION TZ_PROPERTY LINE/o'1 1P6 ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE �- 'OSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE REBY CERTIFY THAT 1 HAVE PREPARED THIS APM.ICATION AND THAT 111E WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULER I REGULATIONS OF THE SAN JOAGUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF 1HE WORK FSR WIIICH \V I PERMIT IB ISSUED,1 SHALL NOT EMPLOY A14Y PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WOWMAN'9 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOn'8 HIRING OR C/) -CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PEnFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO 4-- WMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. VED X N-v v l i'1`��JVV TITLE:—� L7 r 1-y C'.i,4- TS DATE: PLOT PLAN(DRAW 10 SCALE)SCALE JAMES OF STREETS On ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCA71ON OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED )UTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMS. AMENSIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON +CLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. r /N., n v Q-4All Ail IT 061r 28199 -2c _ E ip -11 norf�h;!gRl7ff ski r 1.NEat.rl�r; S l y : FOR DEPI\RTMENT USE ONLY •LIGA.TIO/N ACCEPTED BY --- 7 ' - �-e / DATE I `-'� CJ�i C� / A.'IEA: / i/ Z- jK,MLOR RUMP INSPECTION B DA 1�1 J FINAL INSPECTION BY� y ��D TE/�7 TITIONAL COMMENTS: ACCOUNTING ONLY: AID( FACT PE CODE FEE INTO AMOUNT RETRI I TED ITECKI/C SH RECEIVED BY DATE SR/PERMIT NUMBER INVOICE Pub.Health Serv.-Enviro.174(3/96)