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APPLICATION FOR 1.1011)W.STE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)465-3420 <br /> NOR-REFUNDABLE PERIAIT EXPIRES f YEAR F OM VATISSUED <br /> - (CNmpMLN M TrwiestF! <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAcrum COUNTY FOR A PERMIT TO CONSTRUCT AN01p Rt RRSTALL THE WORK DESCm FD. THIN APPLICATION IS MADE IN COMPLIANCE WIT"SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN MAOUN COUNTY PlU8L)C HEALTH SERVICES,ENVIRONMENTAL HEALTH CIVISION. <br /> 1 l 1 D,TyI <br /> JOS ADOREBSAR APN/ LOT SIZE <br /> OWNERWS NAME fAOOIWESS V ` <br /> . _ RTIONE . <br /> CONTRACTOR •ADDRESS I I !'1' - I i 1 <br /> )JCI PHONE <br /> k SVS CONTRACTOR ADOPESS Int LICI PHONE <br /> TV"OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRlADmnON❑ DESTRUCTION L7 <br /> -�' INC SEPTIC SYSTEM PE/UATTCO IF PUBLIC SEWER IS AVARVBLK WITHIN TOO FEET OF sUROI"G.I PTHC T_11.A I I HOW MARY�� <br /> F� f� AppKwllsn E. INSTALLATION WILL SEINE: RFSSOENCE E3 COMMERCIAL(3 OTHER Li <br /> NUMBER OF ITUNQ UMTS: NtMBat OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> CHARACTER OF LOrL TO A DEPTH OF 7 FEET: PITISUMP SOIL CHARACTER: WATER TABLE DEPTA <br /> SEPTIC YANKANUI TRAP D TYFEA.LrO CAPACITY NO.COMPARTMENTS <br /> u PKGI TREATMENT PLANT❑ DIsTANCE TO NEAREST: WELL. FOUNDATION PROPERTY LINE <br /> LIFT STATION D SUE TYPE OF PUMP SAND 04 SEPARATOR RRCLOSED SMEIr11 <br /> LEACNNNO LINE ❑ NO.♦LENGTH OF L NEB pSTAReE TO NLA/S:eT:WELLPOUNOATION PROPERTY LMt <br /> FILTER BED ❑WIDTH LENGTH DEPTH OIBTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> 4 MOUNDED 13wroTn tENOTH DEPTH DISTANCE TO NEAREST:WELL FOUNOATON PRDPEITYtINE <br /> SEEPAGE INTO 13 DEPTH BRE NUMBER DISTANCE To NEAREST:WELL fOUIDATION PROPERTY LINE <br /> 'Z <br /> SUMPS ❑WIDTH LENGTIR OWTN DISTANCE To NFIAEST:WELL FOUNDATION PROPERTY LINE <br /> t['^ DISPOSAL PONDS ❑WIOTH LENGTH DEPTH DISTANCETO NEAF{ESY:WELL FOUNDATION PROPERTY UNE <br /> 1 HERESY CERTIFY TIULT R HAVE PREPARED TMS APPLICATION AND THAT THE WORK WALL BE DONE RR ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND FtWlAATMNS OF THE SAN JOAMRNCOUNLY.HOME OWNERCRUCENSEO A4ENt's SONATURE CERTIFIES THE FOLLOWRAIM 9 CERTWYT14AT N THEPERW RMANCE OF THE WONC FON WHCH <br /> �. THIN PFIMJIT TO ISSUED,t SHALL NOT EMPLOY ANY PERSON M KMH A MANNER AS TO BECOME sUeJECT TO WORKMAN'S COMPENSATION LAWN OF CALIFORNIA,-CONTRACTOR'S HIRING ON <br /> SUBCONTRACTING SONATIM CEATIRESTHE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WHORL fOR WHICH THIS PERSAIT IN ISSUED,18KALL EMPLOY PERSONS SUBJECT TO <br /> WWNKMANY COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 MUMS IN ADVANCE FOR ALL REQIIIIIEO/NSPECTIONN,COMPLETE ORAWIPG snow. <br /> SIGNED it TTIf 4 r' `rr oATE: <br /> PLOT PLAN WMW TO SCALE)SCALE-,IP <br /> W.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PPOPONEp <br /> I;.OUTUHE OF THE PROPERTY.LOTH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL WITlUt. <br /> O.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,ONVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PRDKRTY <br /> f <br /> ............ <br /> -- <br /> r <br /> :. <br /> .iJ <br /> � r <br /> r ` <br /> } + <br /> : <br /> 4. <br /> PAYMI�N <br /> r <br /> SANJOA <br /> ........ :.-- trnriAaHal [rff <br /> c�luh�v. <br /> ss�v�c�s <br /> FOR DEPARTMENT USE ONLY w <br /> APPlXCA710N ACCEPTED BY - _�. DATE: IIs t'U`�"T AREA: <br /> TANK,PFT OR SUMP INSPECTOR)BY DATE ! I FINAL INSPECTION SY DATE I A <br /> ADDITIONAL COMMENTS: <br /> E ACCOIRiTINO OTRY: AID. FACE <br /> L / l <br /> A PE CODE FFE INFO AMOUNT INDMITED 'CIIECR/ICASH RECEIVED ET DATE MPPEIM11 NUMBER I <br /> i <br /> Pub.heafth serv.-EnVirD.174(3188) <br /> 6 � 5 <br />