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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � {� ENVIF ENTAL HEALTH DIVISION (� P,O,BOX 388,304 EAS. ,EBER AVENUE,STOCKTON,CA 95201388 �.► 12091466.3420 11 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmpAtB In TTglkatB) 'PLICATION 18 HEREBY MADE TO THE BAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN AGUIN COUNTY DEVELOPMENT TTIT//L��E,CHAPTER 0-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH/SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESWOR APNI 1Q S I �1 .w�6Y��v-(SrP^-g'� CIN !i n C'�i ��(I/�L,OTT/SIZE!0 VNER'S NAME L e>c r y RJok g hA✓L ILS L ADDRESS /� -S<_o/ e / PHONE . 9—'w )NTRACTOR ADDRESS yam �"Y.')�( �� UC/ PHONE 2<a-2 773 5 6VB CONTRACTOR ADDRESS LACI PHONE PE OF SEPTIC WORK: NEW INSTALLATION Er REPAIRIADDITION ❑ DESTRUCTION❑ O SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.) PER.TEST(.)1 1 NOW MANY Applloetlon/ INSTALLATION WILL SERVE: RESIDENCE rY COMMERCIAL Cl OTHER❑ "WISER OF LIVING UMTS:_NUMBER OF BEDROOMS: --3 —NUMBER OF EMPLOYEES: ��1 IARACTER OF SOIL TOA DEPTH OIF1----�� 3I1FEET: P-qo Z, PFT/BUMP SOIL CHARACTER S'�-jjoP WATER TABLE DEPTH 7TIC TANK/GREASE TRAP EOTYPE/FIF(3 1 _ CAPACITY 121, bo NO.COMPARTMENTS�L- KO TREATMENT PUNT❑ DISTANCE TO NEAREST: WELL 101)t FOUNDATION 15 E PROPERTY UNE iA(It UFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) A HINO UNE El'NO.•LENGTH OF LINES �-� 1 n1 DISTANCE TO NEAREST:WELL I n FOUNDATION_PROPERTY UNE .TER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE v MOUNDED ❑0WIDTH_LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PRS 10 DEPTH _SIZE .�1.+II NUMBER 3 DISTANCE TO NEAREST:WELL__J_CMZ FOUNDATIONS_PROPERTYLINE Z " N IRA ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE T SPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE O IAEREBY 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 F�T, AND REGULATION:OFT HE BAN JOAGUIN COUNTY.HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:')CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FORWHICH \V THIS PERMIT IS 19 UED,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 Qll -''B-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO �- OWMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION—S, COMPLETE DRAWING BELOW. eIGNED X TITLE: aVI�rC 1 15 7 DATE: YU PLOT PLAN(DRAW TO SCALE)SCALE 'Io NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 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. THE PROPERTY OR ADJOINING PROPERTY. x�. . ! pR{} . 0., .: ..... ... .. MA co.- . DCT2 g _. �cc>N1997 II E Nr,O I FOR DE► TMENT USE ONLY DATE: / '� r V —� AREA: �''�PL-(CATION ACCEPTED BY TANK,6I GR BUMP.N.PECT.OH B DAT /� FINAL INSPECTION BV��z`J �0� SATE/d �?, v7 "ODRICONNAL COMMENTS: '1 ACCOUNTING ONLY: AID/ FAC! PE CODE FEE INFO AMOUNT ROv111 TED IIECK/IC BH RECEIVED BY DATE BN I PERMIT NUMBER INVOICE F 115C ns / 0 aoo3 1a�sk� y05 Os��sl I� Pub.Health Saw.-Enviro.174(3/96)