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Now SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOCY,TON,CA 96201383 (209)460-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmpIBt.iR Tripli-t.) APPLICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER B.111`0.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. J08 ADDRESSKOR AM' 1 31 ✓ W ` • `�� Clry� C�• �� LOT SIZE OWNER'S NAME l' � /�C% fG� ADDRESS - �i PHONE - �j q^T�7� CONTRACTOR_ n iyk- isat- ` ADDRESS to �Dk �OS 0 UC/ SUB CONTRACTOR ADDRESS UC,. PRONE TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPFJR/A..,,.N wr DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILOMGI PER.TESTW I I HOW MANY INSTALLATION WILL BOWE�ENCEU COMMERCIAL❑^j OTHER❑ NUMBER OF INNO UNITS: NUMBER OF BEDROOMSNUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: 5 C-A • PTISUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKUGAEASE TRAP ❑TYPF1MF0 CAPACITY NO.COMPARTMENTS —_ PKU TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE UFT STATION❑ SIZE TYPE OF PUMP SAND Olt SEPARATOR(ENCLOSED SYSTEM( \ T LEACHINO UNE r❑Y NO.6 LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION U. PROPERTY LINE x __ FILTER BED 1O WIDTH LENGTH��DEPTH _DISTANCE TO NEAREST:WELL�O _FOUNDATION '1 c� PROPERTY LINE 1 V y 1 MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE 1U SEFSAGE PTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE ,\ SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES v AND REGULATION:OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERT IFYTHAT INTHE PERFORMANCE OF THEWOPK FORWMICH THIS PERMIT IS ISSUED,I 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 SIGNATURE CERTIFIES THE FOLLOWING:'1 CFRTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSA�T ION L/AWS OFF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW SIGNED X /L it�/l�-f/l TITLE: cv 1!i-r C �\ DAI E: C PLOT PLAN(DRAW TO SCALL(SCAT E 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TILE PROPERTY. Oo4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 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, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. I HE PRo PFRTY OR ADJOINING PROPERTY. s RFT b - s ya FznGe, FOR DEPARTMENT USE ONLY .-1BLICHEALIH 1.I?'/1� APPLICATION ACCEPTED BY DATE: TANK,PIT 09 SUMP INSPECTION BY DATE / / FINAL INSPECTION By DATE / / ADDITIONAL COMMENTS: ACCOUNTING ON1 .(( AID/ PE CODE IESHI AMOUNT RQMII TED CHEC .ASH RECEIVED BY DATE BIL/P61MIT NUMBER INVOICE/ 3-)0 1 ID 1 u 3 11 79 El Pub.Health Se-�EnvirD.174(3,'96)