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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DI'' 'N P,O,BOX 388,304 EAST WEBER AVENUE, CKTON,CA 95201388 11J (109( 488-3420 v I MON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comploo In Triplicm.) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPIJCATION 18 MAGE IN CONIIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT lTITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF AN JOAOVIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESS/OR APNIr1 10 S)^� CITY L�C�i �LOOTTJ&ZE� WNC OER'S NAME L >o r i V Ok Q nLY\!• A/X rADDRESS las Cgs �Q9—)-773 CONTRACTOR L-t ADDRESS 'Y.( C� LICI �Ff$�j-C'I MOVIE .$ 8 SUB CONTRACTOR ADDRESS UC' PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAMIADDITION ❑ DESTRUCTION❑ (NO SEPTIC SYSTEM PERMITTED IF PUBUC SEWER 16 AVAILABLE WITHIN 200 FEET OF BUILDING.) PER.TESTW 1 1 HOW MANY INSTALLATION WILL SERVE: RESIDENCE j/ COMMERCIAL 11 OTHER❑ NUMBER OF LIVING UNITS:_L NUMBER OF IrE,DROOMf: NUMBER OF EMPLOYEES: ��1 CHARACTER OF SOIL TO A DEPTH OFFI---3I,�FEET:ACgQnk]p RT/SUMP SOIL CHARACTER, S---JCP WATER TABLE DEPTH SEPTIC TANK/GITEASE TRAP LGTYPE/MFO Y I � CAPACITY I ), a'7 NO.COMPARTMENTS} ►KG TREATMENT PANT❑ DISTANCE TO NEMUT: 1 WELL I aCl 1 FOUNDATION rj r PROPERTY LINE UFT STATION❑�IZ � SIZE TYPE OF PU/MP SAND OIL SEPARATOR(ENCLOSED SYSTEMI LEACHING LINE Ir NO..LENGTH OF LINER ,7- �C I DISTANCE TO NEAREST:WELL (<�r) FOUNOATION-1-L-2_PROPERTY LINE10(7 p FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE (.1 MOUNDED ❑yWIDTH_LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 1 SI EPAOE PIT& IO DEPTH SIZE HUMBER DISTANCE TO NEAREST:WELL(�!7! FOUNDATIONS_PROPERTY LINE ( �. `U 2 SUMPS ❑IMOTM LENGTH DEPTH DISTANCE TO NEAREST:%JELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WID7H LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE C I HEREBY 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 FT AND REGULATIONS OFTHE BAN JOAOUINCOUNTY.HOME OWNERORUCENSED AGENT'S SIGNATURE CERTIFIESTHE FOLLOWING:-ICERTIFYTHAT IHTHE PERFORMANCE OFTHEWORK FORWHICH \' THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOIWIA.' CONTRACTOR'S HIRING,OR 6U0-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO �l WORKMAN'S COMPENSATION LAWS OF CALMD)�WIA.- THE APPLICANT MUST CALL 24 MOURf IN ADVANCE FORALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. R SIGNED X �" /j1`.'-/ETITLE: /S-DYI�rC C-+7bI- DATE: ROT PLAN(DRAW TO SCALE)SCALE 1.NAMES OF STREETS OR ROAD$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 DIg-SAL 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 WALXS. THE PROPERTY OR ADJOINING PROPERTY. 'U�1 S^' 7Q •'p� /y. ... �= Uzy t" ,.... 00T 2 8 Et,,P u�HErrt c�untry ,RrAL .NEattrVISloN .. .... ..... :..... ..... FOR OEP/UtTMENT USE ONLY DATE: A/P�P-L-JCATT�IO�N ACCEPTED BY I 7' / a r �'I K"////,/-� "w AREA: h / y^� J TANK,RYOR BUMP INSPECTION B DAT/ / FINAL INSPECTION BY �i�r/_ O SATE/K� lJ ADDITIONAL COMMENTS: M..COU.Tl.. NLY: AID' FAC' FEE INFO AMOUNT REMITTED (IEC K'IC SH RECEIVED BY DATE 6R/PBIMIT NUMBER INVOICE' SCO//s / ' oo Pub,Health SeN.-Enviro.174(3/96)