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k- N JOAOIIIN COUNTY PUBLIC HEALTH SERVICE' - ENVIRONMENTAL HEALTH DIVISION 'r P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 O Py (109) 4883410 BION REFUNDABLE PERMIT EXPIRES l_YEAR_fROM DATE SSUED (Complete In Triplicate) AT".(CATION 18 IIFIIFRY MADE TO THE SAN JOAQUIN COUNTY FOR A PEINSIT TO CONSTFIUCF AND/OR INSTAI L THE WOFK DESCRIBED. THIS APIA ICATtON IS MAIN:M COMPLIANCE W11H BAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPIER B-1110.3 AND TIIE STANDLRDB OF BAN JOAGUtN COUNTY PUSLIC IIEALTII SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR ATM!/ f L4GPO �/V /4;; _-t A CITY 7 _ALOT SIZE OWNER'S NAME / , ADDRESS �/^�� ,l�,� j(f 0/, � fM10NE _1 CONI RACTOR�_ LL7�i'`��'`� AD011E RB �j. //��<�7ly�G) LIC PHONE l BUS CONTRACTOR AODRFSe tics PLIONE TYPE OF SEPTIC WORK: NEW INSTAttAtION RFPMR/Ant4110N ❑ DFe1RUC110N ❑ INO SEPTIC SYSIEM PERIMIITED IF P1RlIC 6FWER 18 AVAILARI E WITHIN 700 TEET OF RIIBDIN0.1 0 PERC TESTI.( 1 HOW MANY APrA—don s INaTA1LAT10N WILL SERVE: RESIDENCE❑ COMMEnCAAL OUTER ❑ CT '/ �• NUM8FR OF LIVING UNITS: X NUMBER OF SEDROOMII:— NUMBER OF EMPLOYEES: - C CHAMCTER OF 6011 TO A'DEEPT'H OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPT( l SEPTIC TANK/GREASE TRAP ❑TVPf/MF _CAPACRY� NO.COMPARTMENTS C ►KG TREATMENT PLANT 11TJ DISTANCE TO NEAREST: WELL 9 FOUNDATION PEIOPERTY LINE �— LIFT BTATION❑ 617E TYPE OF PIMP _RAND 011.SEPARATOR IENCLOSFU SYSTEMI _ LEACHING LINE 1KNO_e LENGIH OF LINES -4,/— (•Yj/Gr- DISTANCE TO NEAREST:WELL_Ly��rOUNDATION��//PROPERTY LINE �( /( / FILTER BED ❑MUTH LENGTH DEPI11 DISTANCE TO NEATIEST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENOIH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PITS ❑DEPTH BIIE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH 0181 ANCE 10 NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENOIH DEPTH DISTANCE TO NEARFBT:WELL FOUNDATION PROPERTY LINE I HERESY CERTIFY THAT I HAVE PREPARED THIS APFAICATION AND THAT THE WOII(WTIL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REOULAI PONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENRED AGENT'S SIGNATURE CERTIFIES THE FOI LOWING:'1 CERTIFY THAT IN THE PERFOROAANCE OF THE WORK FOR WHICH Title PEI1MIr IB ISSUED,1 SHAM NOT EMP OY ANY PERSON IN SUCH A MANNER AS i0 BECOME SUBJECT TO WOPI(MAN'S COMPENSATION LAWS OF CAI IFORNIA.' CONTRACTOR'S 141FUNG OR SUB(CONI RACTINO SIGt1AIURE CERTITIES THE ED[IOWING: '1 CERTIFY THAT IN 111E PERFOEIMANCE OF THE WOFK FOR WHICH THIS PERMIT 18 ISSUED,1 SHAH EMP OY PERSONS SUBJECT TO WORKMAN'S COMFINSAI PON LAWS OF CALIFOR-NIA./x'11HE AP%)CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLLIE DRAWING BELOW. SIGNED X_ J�`/ �L�' �� TITLE: �hs2, �.L OAT E: � I1.01 PAN IDRAW 10 SCALFI SCALE 'to 1. NAMES OF STREETS OR ROADS NFAREBt 10 OR BOUNDING THE PFK)PERFY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OIIIt INF OF INE P ROPERIY,MITI DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM$. 3. DIMENSIONED OUTLINES AND LOCATION OF All EXISTING AND PFOPOSEO 8ttWC1URES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVEFIED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIKS. THE PROPERTY On ADJOINING PROPERTY. PA � 4, //`f-' L l FOR DEPARTMENT USE ONLY q APP ICAIION ACCEPTED BY� � -�c_1 " DATE: •� A A a / TATS(,PIE OR SUMP IN61'FC I MIT BY (DATE 1 }�--.�}—�fMNLtiNBPECTKTN-BY .-i`,L - 1.- . DATE__/ AUDI I Ir)11At COMMf N1 S:_ -�G..�`l� ] U-E/l4 /L- ,ti,�✓✓Yw �'/ ��- � p�'L�2 fLr o�1 =mak ACCO UNTINO ONLY: AID/ FAC$ FPE CODE FEE INFO AMOUNT REMII TED CIIECK//CASA REcnvEO eY DATE M/PETIFMT NUMBER INVOICE L-, - - -- - --C / " l Pub Health Sery -Envlro. 174(3/96)