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APPLICATION FOR LIOUIO WA PERMIT SAN JOAIIUIN COUNTY PUBLIC H 1 SERVICES ENVIRONMENTAL HEALTH D1GISION P.O.BOX 388,445 N.SAN JOAOUIN ST., STOCKTON,CA 95201-0388 12091 408-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - ICompleEB in TFplic t.j APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI {'J C�/O/�I S/eU L�� //T CITY AG/4,en Po _ 2LOT SIZE L� OWNER'S NAME / D r i Ol/yA /L�^_`,yI ADDRESS .yf, ^(/D, rs( ///1��J C�GCJ L li PHONE CONTRACTOR L E R`R R l/SCJ�• ADDRESS �cl-L ,l /J V�m�7U )JCI n L�1 PHONE 3��✓y ��y3 jI SUB CONTRACTOR /,f / l Imo(//`/-P ADDRESS �Q i f/��)l"� LICK/-'S.5,].sC PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION IRI REPAIMADDITION Pf DESTRUCTION❑ / (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PER.TESTI.11 I HOW MANY APPI.-. l INSTALLATION WILL LEAVE: RESIDENCE 4Z COMMERCIAL❑ OTHER❑ NUMBER OF UVINO UNITS:_I NU.IBER OF BEDROOM[�1:�� _NUMBER OF ISM—YEES: N CHARACTER OF SOIL TO A DEPTH OF 3 FEET:?•L) PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE/MFG L F CAPACITY 44&v / NO,COMPARTMENTS 11P, e PKD TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL �C/P FOUNDATION ✓ h PROPERTY LINE I� UFT STATION❑ SIZE TYPE OF PUMP /'n SAND OIL SEPARATOR(ENCLOSED SYSTEM) ',l LEACHNO UNE W NO.N LENGTH OF LINES --':P-" C, r� DISTANCE TO NEAREST:WELL�h l r� C;` / PROPERTY UNE .��I '- FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE p MOUNDED ❑WIDTH LENGTH_DEPTH qq DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE x SEEPAGE RTS 13 DEPTH SIZE L-36 NUMBER V DISTANCE TO NEAREST:WELL 1Tp t a0NDATION �//,,/,fl-.PERTY LINE 1v LUMP[ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PIOPERTY LINE DISPOSAL POND[ ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOMEOWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLO WING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOWMAN'6 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-COM NTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE Of THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 34 HOUR[IN ADVANCE FOR ALL REGUIRED IINSSnCTIONS, COMPLETE DFUWING BELOW. ',/L/ L, y SIGNED X /' / TITLE: , � DATE: ROT FUN(DRAW TO SCALEI SCALE IE 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTUNE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNES 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. a TTCC" \ � U `t� mol 710 P IQ Woo"Ie 0 PAYMEW B_ SEP ; % 1995 DAN JGAc .� LNV RlJNMF^T.,i '�1ITI FOR DEPARTMENT USE ONLY 11(' APPLICATION ACCEPTED BViT �� '��/1 �""/ DATE: y 1y� A (��j AN T SVMP INSPECTION 8V Gnu DATE r� FINAL INSPECTION BY� [ n ATE %l r-G.% 7 l7 ADDITIONAL COMMENTS: ACCOUNTING ONLY: AIDE / FACE t- "I Qd PE CODE FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE SA/PERMIT NUMBER INVOICE E 7—,) C4 960CP c 3 3a7 r/,, sys7�