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s I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALIN DIVISION P.O. BOX 388, 304 EAST WEBER•AVENUE, STOCKTON, CA 9MI X88 (2091469-3420 NON-REFUNDABLE PERMIT EXPIRES f TEAR FROM-DATE ISSUED (Compbtr M TTMplkrtr) ' -� { ' APPLICATION 19 HEREBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN { 1 JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1110.3 AND THE ST'A^N�DARD/S�OF�SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, a �1 11 JOB ADDRESSOR APNN p }�C. 1 O! x s / � CITY � w LOT SIZE g A t`e S ONMEq'B NAME{,�a 1` GnSq I� /t�fa�� ADDRESS.--� 1 2(r L f , Z A Q C -o•t/ -E '••.•�p}{pNE q�/�3l CONTnAC%R 1 VTI t�q,�A S l„ Q�yV[�S1�AM)`IM��&FIFSB_. - / d��rA /� {� UC/ a tU PHONE - SUBCONTRACTOR_lnAC L1 A,T��-1��wyYy A111ES135 3 N �, L�1 YV11i 1�Y -UCL l I PHONE, S9 L TYPE OF SEPTIC WORK: NEW INSTALLATION yT REPAIRIADDITION ❑ DESTRUCTION❑ INO SEPTIC SYSTEM PERMrTTED IF PUBLIC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDING.( PEA TESTIr)ILMI NOW MANY INSTALLATION WILL SERVE: RESIDENCE aq COMMERCIAL❑ OTHErI 11NUMBER OF LIVING UMTS: NUMBER`OF BEDROOMS:_ NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKIGREASE TRAP ©TYPEIMFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE I UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) 1 LEACHING UNE ❑ NO.S,LENGTH OF UNES DISTANCE TO NEAREST:WEU-__}_FOUNDATION PROPERTY LINE {` a FILTER RED ❑WIDTH LENOTH DEPTH DISTANCE TO NEAREST:WELLS FOUNDATION PROPERTY LINE �J MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE �. SEEPAGE PITS ❑DEPTH SIZE NUMBER OISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE BUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST.WELL— FOUNDATION PROPERLY UNE DIBPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL—Jr.Jr—FOUNDATION PROPERTY UNE - I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE:WORK WILL BE DONE IN ACCORDANCE WIT.11 SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUINCOUNTY.HOME OWNERORUCENSEDAOENT'SSIONATURECERTIFIERTHEFOLLpYANOI'ICERTIFYTHATINTHEPERFORMANCE OFTHEW'ORKFORWMICH CA THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOnKmAm-9 COMPENBArION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLIOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOA WHICH THIS PERMIT TS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO ^ WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALy REQUIRED INSPEC�JTION$. COMPLETE DRAWING BELOW. 1 1 SIONEO% TI11-E:L.l3 , cn J L ``I" DATE: PLOT PLAN IDRAW TO SCALE)SCALE .'0 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING T1IE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED �v 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, I S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON s INCLUDING COVERED AREAS SUCH AS PATIOS,ORRVEWAY9,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY, . ... .. .. .. .. : ....;.. : . ... ... xi j�. ...... v.. .. . .. c- t .c ,S' .. .. FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY -�C_..(/1 �`'� ��(,�Y� DATE: l% AREA: I�_ TANK,PIT OR SUMP INSPECTION BY AO01110NAL COMMENTS: ACCOUNTING ONLY; AIDS FAC# — — b PE CODE FEE INFO AMOUNT REMIT TED SH RECEIVED BY DATE SR I P19tlU11T NUMBER INVOICE I a� 533 U5 I a f Pub.He91Ih Serv.-Enviro.174(3196) I �.