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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 358,304 EAST WEBER AVENUE,STOCKTON,CA 96201388 (2091 460-3420 NON-REFUNDABLE PERFAIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Trplicstal APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/Oft INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRO�N/MEMAL HEALTH DIVISION. JOB ADDRESSOR APNF /6 701 L' /l I V' IC-0 CITY- x"', `, LOT S1ZE yG ///J /)') /� / ,1 fFGr45 OWNER'S NAME ///L77/�I/�/ FN//R`/D%/Sh5• ADDRESS //J]C)UC/1/�Jti/ rL JA PHONE C'?CONTRACTOR /}//[//JM L�/FS 7 ADDRESS LJC.I )1 PHONE BDB CONTRACTOR 7/ ^� �A'7/ ADDRESS �� SXk'�rT-'r �/�%tE /�/ :� UC11-f JSJ L��' PHONE 'S7y'-.3/Y 3 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION❑ DFATIRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PTHC TESTI.)1 1 HOW MANY APPEaetl—e INSTALLATION WILL SETIVE: RESIDENCE❑ COMMERCIAL OTHER❑ NUMBER OF LWING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: S /`�A PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH } SEPTIC TANK/GREASE TRAP ❑TYPE/MFG ONG CAPACITY /zUO 4,11 NO.COMPARTMENTS L WO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL YzS FOUNDATION T PROPERTY LINE UFT STATION❑IX TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACHING UNE IX NO.S LENGTH OF LINES J 'A DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE NTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAGUIN COUNTY.HOME OWNER OR LICENSEO AGENT'S SIGNATURE CERTIFIES THE FOLLG WINO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X �I I/"'1 ' TITLE: e�2111I DATE: PLOT PLAN(DRAW TO SCALE)SCALE 'to 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING 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 SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. (.THE PROPERTY OR ADJOINING PERTY. y'FAL ` P"�� /Zoo 71 wrl'M , Ley RKfRS ... .. ... ..:. '. ...........i. .`.....,..ESIW4F; euc I�rH sEstsce, ... .... . ONMEJCTAL ..... >...... .:.... ......,.. ..... .:.. -. 5',I�tirktv6 r FOR�D E7P—TTTj—E-NTTT USE ONLY APPLICATION ACCEPTED BY "— y" _ DATE: TANK,NT OR SUMP INSPECTION BY DATE / / FINAL INSPECTION BY I DATE /Z3/ ADDITIONAL COMMENTS: v �� 2 E� w ti 7-b Be Ctl*VGEn TD ? e O % 2 � •�8tt. CSC ACCOUNTING ONLY: AIDS FACS PE CODE FEE INFO AMOUNT REMI I TEDCHECK)CASH AECRVED BY DATE SR/PERMIT NUMBER INVOICE E 25-U 2-moo,oc) Zag a Pub.Health SEN.-Enviro.174(3/96)