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SAN JOAOUIN C T PUBLIC HEALTH SERVICES ENVIRONtT%.,,L HEALTH DIVISION P.O. BOX 338,360 EAST WEBER AVENUE,STOCKTON,CA 95201-W U (209)4683420 9 1 i M S 1 _ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED LI\ i i4 '1 l> (J� _� C�{�L`r,1^''�/" ICempBb in Triplicate) APPLICATION 19"EREBY ADE TO TCSAN JOAOUIN COVNTf FAF M PE WIT TO CON9TRNrT ANDIOR INSTAL(TIIE WOW DESCRIBED. TNIB APPLICATION IB MAGE IN COMPLIANCE WITH SAN JOAOVIN COUNTY . DEVELOPMENT TITLE.CHAPTER 9-1110.33AND TIISt ANOARn6 OF SAN JOAOUIN COUNPUBLIC UNBLIC HEALTH SEnVICES.ENVIRONMENTAL HEALTH DIVISION. JB ADDRESS/OR APN/ /l12V 00-7 —06 _ — 4-7 CITY LO T SIZE WNER9 NAME •QAJ STN E-/L)S —DRESS I0750 741A(4T R.D. CA-M Po Cs�N6 CONTRACTOR ADDnESS LIC/ MONE 'IIB CONTRACTGA _nNDRESS LICP_ PHONE YPE OF SEPTIC WORK: NEW INATALLATION PEPAIRlADIXTION❑ DFSTn UCIION afta,4o SEPTIC SYSTEM PERMITTED W IF PUBLIC SEER IS AVAILABLE WITHIN ion FELT OF BOT(VINC.J —C iEb Tlsl 1 1 NOW MgNY I AnMlnntlon INSTALLATION WILL SERVE. nESIDENCF� COMMERCIAL❑ OI HER❑ LIMBER OF LIVING UNITS: NUMBER OF SEDROOMS: NLXUAER OF EMPLOYEES: HARACTER OF SOIL TO A DEPTH OF J FEET: MYISUMP SOIL CHARACTER'. WATER TABLE DEPTH 181EPTIC TANK/GREASE TRAP ❑TYPE/MFGCAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ 617E TYPE OF PUMP SAND OIL 6FPARAIOA(ENCLOSED SYSIE.MI EACKNO UNE ❑ NO.S LENGTH OF LINES D18TANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE —_ rol,I am ❑-011, LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH- DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNF _J SEEPAGE P16 ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PPOPRTY LINE LIMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE IISPOIAL PONDS ❑MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE /1 tat" �J 1 HETIEBY CERTIFY THAT 1 HAVE PREPARED TH19 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANDREOULAT IONS OF THE SAN JOAOVINCOUNTY.NOME OWNER OR LICENSED AGENT-0SIGNATURE CERTIFIES THE FOLLOWING!-I THAT IN THE PERFORMANCE OF THE WORK FOR WHICH ,-.-7 THIS PERMIT IS ISSUED,I SHALL HOT EMPLOY AVIV PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN-6 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING On 1 UB.CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 19 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO JOPKMAN'8 COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 34 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS. /COMPLETE DRAWING BELOW. �SIGNED TIT / ✓ LE: C L V G L �F'VCJ F� DATE: :< / ROT PLAN IDRAW TO SCALEI SCALE ( I OD1. F NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING TIIE PnOP1TrY. n4.LOCATION OF HOVSE SEWAGE DISPOSAL SYSTEM OR PFIKIMSED T.OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. JW DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND IpWpo SEO STRUCTURES, 6,LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. —•1 AMU MHLS.It MAl.rl E 1 9114:N ' V1"ai wm"claL 5cc-10 '1 5c.it MID.B., 4 M. J i JAHMITROAD z— — f——_ .Lc CGS`CG (lwo 5Ec.t5 Sac-14 r 1 K �X. ,P 4� iJ Te LI IIs I rn 0 8 33'8 I� . II jot; 4, SAN JOZN GDUNIY r„ P11F3LYC HEALTH SEFNIGE.' I "\ ENVIF1oNMENTAL HEALTH DM-"i'r- cant / FOR DEPAATMF.NI USE ONLY L9., APPLICATION ACCEPTED BY I _DATE: ARE ' ^ 1 / ILFTANK.PR OR SUMP INSPECTION BY DATE I I FINAL INSPECTION BY ATE // � ADDITIONAL COMMENTS: + y ACCOVNUNO ONLY: AIDE FACT PE CODE rEE Nr0 AMOUNT HEMI TED HECK/CASV/ RFCDVEO BY DATE SIR/PTRMIT Nl1MBEi INVOICF LI i Pub.Health S.'.•Enwo.174(3196)