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001-sll Y JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (208) 46e-7420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in TTlplkate) APPLICATION IB HEREBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDX)R INSTALL THE MW DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1110T.3 AND THE STANDARDS OF BAN JGA/OUIN COUNTY POBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DNISION. JOB ADDREBB/OR APN# N/ 9 �/ ) L �l EYFYawl C A-YI, CITY �1r LOT SIZE ��tsLfK"f� OWNER'S NAME lr O_! , V1C ADDRESS f-1-MG /� PHONE ��i� / / 3 CONTRACTOR ('-14- .LJnC ADDRESS�'�' 1 rY.Tl,n `UJ\y 4 LICIT ~iat PHONE 3ro$-- '1`l33 BUB CONTRACTOR l ADDRESS UCI PHONE TYPE OF SEPTIC WORN: NEW INSTALLATION ❑ REPAIWADMTION 13 DESTRUCTION ❑ (NO SEPTIC SYSTEM PERMETTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) PEW TESTNI 1 I(IOW MANY INSTALLATION WILL SERVE: RESIDENCE of COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: -�� C NUMBER OF SEDROOMS: NUMBER OF EMPOVEES: ¢ 1 - CHARACTER OF BOIL TO A DEPTH OF 3 FEET: (�I r4Y PFT/SUMP SOL CHARACTER: C� -M'Yd WATER TABLE DEPTH SEPTIC TANN MUSE TRAP ❑TYPE/AIFG CAPACITY NO.COMPARTMENTS MET TREATMENT PUNT❑ DISTANCE TO NFAMAT: WELL FOUNDATION PROPERTY UNE (\L1 LIFT STATION❑ SIZE TYPE OF RUMPSAND OIL SEPARATOR(ENGLOBED SYSTEMI I Jam- LEACHING UNE 1?k NO.B LENGTH OF LINES (--)) I U O E DISTANCE TO NEAREST:WELL 100' FOUNDATION L3.7 PROPERTY UNE FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PR ems' f OPERTY LINE SEEPAGR E TS DEPTH �S I SIZE 2` !l NUMBER DISTANCE TO NEAREST:WELL / /0 FOUNDATIN_��PROPERTY UNE 7S E BUMPS 1-1H J WIDTH LENGTDEPTH DISTANCE TO NEAREST:WELLFOUNDATION PNOPERTY UNE /T DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE l I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES q� AND REGULATIONS OF THE SAN JOAOVIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PEBIM MANCE OF THE WORK FORNMICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATU CERTIFIES THE FOLLOWMG:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK MR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSAT Te OF CAIJ MIA THE APPLICANT MUST CALL 24 HOURSIN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMMETE DRAWING BELLOW. SIGNED% �� _TTTLE: n ft_S�fi1L DATE: POT PUN IDRAW TO SCALE(SCALE -tP 1. NAMES OF-STREETS OR ROADS NEAREST TO OR BOUNCING THE PPOPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENWONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS MTHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCUUDINO COVERED AREA$SUCH AS PATIOS,DRVEWAYB,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. Y r U ` i ltr AUG -5 1997 -"- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES v",,.,,r-,' 1n o, NVIRQNMENTAL.HEALTH DIViS10, FOR DIPARTMENT USE ONLY APRJCATION ACCEPTED BY I DATE: ��^/ AREA' TAROK,C)OR BUMP INSMCTIO14 S DATE FINAL INSPECTION BYT'�'��/�� DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: AID' FAC/ PE CODE FEEINFO AMOUNT REd11TED ECX CABI4 RECEIVED BY DATE BR IPBiMIT NUMBER INVOICE/ Pub.Health Sew.-ERvirG.174(3/96)