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JOAflUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 888, SO ,MT WEBER'AV ME, 8 q.!0KTON, CA SIM1�88 (2091460-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICDIRplate In Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANbIOR INSTALL THE WORK DESCRIBED. TH18 TIO 8 M NYE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, t EH 1L HEA T� •JOBADDRE88roRA1'NN 44q 9._1-_-_- t II V 4y�+'�1�n ��CIT'Y 1 ��LL�� LOT SIZE I D 6UVNER'SNAME-_ 'G/') 1 �C.e4f4 T' i't[S ADDRESS PHONE_"`fS„� CONTRACTOR --m FI t'L-fL ru I I.•f.V ADDRESS too. gA r1aC �,�a�" LICN (aj)f$" PHONE �-3j.-7 J73 SUB CONTRACTOR ADDRESS LICN PHONE (� 11 TYPE OF SEPTIC WORK: NEW INSTALLATIONREPMR/AbbITION ❑ DESTRUCTION I LINO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BUILDFNO.I PENC TESTI91( 1 HOW MANY INSTALLATION WILL SERVE: RESIDENCE{d COMMERCIAL ❑ OTHER ❑ NUMBER OF LINO UNITS:_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OFE'33 FEEET:_ 52A Y 1-00M PITISUMP SOIL CHARACTER: WATER TABLE DEPTH IG SEPTIC TANKMIFABE TRAP Ba TYF'EIMFa. e+L Czwya i-� CAPACITY .r_.la,(a NO.COMPARTMENTS PKQ TREATMENT PLANT❑ DISTANCE TO NEAREST. WELL_,J�� FOUNDATION_ PROPERTY LINE LIFT STATION❑��IZSIZE - TYPE OF PUMP [�I�SAND OIL SEPARATOR{ENCLOSED SYSTEMI �i,.,r LEACHING LINE 1cr HO.A LENGTH OF LINE8__.- � -?S J DISTANCE TO NEAREST:WELL��FOUNDATION .+0 PROPERTY UNE i 00 FILTER BED - ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE SEEPAGE PTS fIrDEPTH SIZE fe�-NUMBER__3 -..DISTANCE TO NEAREST:WELL FOUNDATIONS PROPERTY LINE_t121)f SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 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.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFYTHAT 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 WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING 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 APPLICANT MUST CALL 24 14OURN IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED x - TITLE: C(�r1 i""I 7 con 1 DATE• PLOT PLAN(DRAW TO SCALE)SCALE 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 PROPERTY. .. - ., 4 ,{... . .: . .. ..• .<... ....... ... . . .. . .: �.: ..... .... ....... .. .. ..... .:. . . .. ..... ............ .... ... .. . 1 �A i � .. ... p ._ .. ' :: f. .. ...... .. .. .. t MA 1997 ..... .. . 0Nfv1LNTAL HEALTH NV 810 1� ... ... _'''"�^ -." -=^".^•..:.�+�-.-"--- �'.``P"= -�-_-' - --'.:-r+FOA•DEPARTMEFIT USE ONLY AA CATION� EPTEd 8Y . ...-=-- �- DATE: r��__�-� r J [ ] 1 pApi1C,6T R SUMP INSPECTIO14 BY DATE V ! T INAL INSPECTION BY DATE�J fVAD/Dr rIONAL COMMENTS, ACCOUNTING ONLY: AID# FACS PE COVE FEE INFO AMOUNT REMI I TED CHECKNICASH RECEIVED BY DATE SR J PERMIT NUMBER INVOICE N ' 1 6. �- Pub.Health Serv.-Enviro.174(3196)