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vIN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION Ift.i P.O. BOX 988, 3D4 EAST WEBER AVENUE, STOCKTON, CA 95201308 (2091469-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (C{mplPt{In Trlpli{St{I APPLICATION 18 HUEBY MADE TO THE BAN OUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAOIBN COUNTY DEVELOPMENT THU.CHAPT 110.3 AND THE S ANDARDS OF BAN JO QUIN COUNTY PUBLIC HEALTH SERVICES,ENVISON41ENTAL HEALTH DIVISION. i JOB ADDRESSORA 9 G / CNY l LOT BIIF (' A C �.I tY t Y DFJ �j -E j OWNERSNAME Llvk - `)O--A JLC IBJ ADDRE99 O l�` 1,,LO WA L'��' `FI14Y PHONE -{/�.�y 1i-' I SIO CONTRACTOR ADDRESS !j!e�gyy��kk /(��/Jyl`x ' SEAN'(- LIC1�Y25°13 RIONE �G JL-0 � 6UB CONTRACTOR ADDRESS nirv_w I CA -L 5 z' r— LIC) PHONE TYPE OF SEPTIC WORE: NEW INSTALLATION REPAIR/AOdl10N ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 19 AVAILABLE WHHIN 200 FEET OF BUILOINO.1 PFRC TEBTI.I I I)IOW MANY � / Aedle.So.I INSTALLATION WILL{EINE: RESIDENCE lk" COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS:_I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: eft �e. 1 CHARACTER OF 601E TO A DEPTH OF Q FEET: ,JF•LnF� /Rt T�/SUMPj�8�.0jj MARACTER: .FTIr 17 WATER TABLE DEPTH IS �ff SEPTIC TANRITFA6E TRAP ®TYPF/1AF0 VC/AK.i�'T CAPACITY 1•�ZOIJ QUA,1.(,OiL! NO.COMPARTMEMB c. PLG TREATMENT RANT❑ DISTANCE TO NFMFIT: WELL I W 2+ FOUNDATION PRpPnrY UNE 1,50, LIFT STATION❑ SIZE_TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE ID NO.B MOTH Of LIMB 4- .7 S P DISTANCE TO NEAREST:WELL,TFOUNDATION 3 V N PgPRTY UNE 15 N FILTER RED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PRORnTY LINE MOUNDED ❑YnDTH MOTH DEPTH DISTANCE TO NEAREST:W M FOUNDATION PROPERTY LINE SEEPAGE PTS [3DEPTH BRE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION POPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PIOPRTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PNOPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORE WILL BE DONE IN ACCORDANCE WALL!SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN"AMIN COUNTY.HOME OWNER ORUCENWD AGENT'S SIGNATURE CERTIFIES THE POLLOWINO:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(POR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COMRACTQR'8 HIRING OR SUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PEIIMIT IB ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X �v ntky L� TITLLE:� 1 W`�-- DATE: I ZIII�?-I PLOT RAN(DRAW TO SCALE)SCALE --- iii 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDINO 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 SYBTEMB. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND POPOSED STRUCTURES, S. LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIKB. THE PROPERTY OR ADJOINING PROPERTY. I'j j Ol i (-P) Bo X L�2po 'RrhZDG-I�C� IDD f DEC 2 Wgi1 SAr V,/(NINVignas.,I.(. .. OR DEPARTMENT USE ONLY < Y APPLICATION ACCEPTED BY DATE: A: TANK,PT OR SUMP INSPECTION B DATE I / FINAL INSPECTION BY ADDITIONAL COMMENT S: i ACCOUNTING ONLY: ADN FACIF PE CODE FEE INFO AMOUNT REWITED CDECKi SH RECEIVED BY DAT SRIPERMITNUNUER INVOICE IL Pub.Health Serv.-Enviro.174(3/96)