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hN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> `/ ENVIRONMENTAL HEALTH DIVISION -.R/ <br /> P.O.BOX 388,304 EAST WEBER-AVENUE.STOCKTON,CA 95201 88 <br /> )209)468-3420 <br /> RON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICDInpIJtJ In hiP5-u) <br /> /UFUCATON IS HEREBY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTBUCT AND/OR WST ALL THE WOW DESCRIBED.TMS APPLICATION W MADE W COMPUAM <br /> JOAW,,COUNTY DEVELOPMENT TITLE.CHAPTER 9-1110.3 AND THE STANDARDS OF SAN�-ATN COUNTY PUBLIC HEALTH SERVICES. <br /> EEVVIIRONMENTAL HEALTH DIVISION. <br /> Job ADORESSIOR APH/ AQD /CI1LI�� <br /> H / C�I"-T^Y W <br /> LOT <br /> OWNA'S NAME I'W — PHONE .5&17 <br /> 'S/ f� PHONE/GUCJ <br /> CONTRACTOR f5lS(V L— ADDRESS <br /> SlM CONTRACTOR ADDRESS LKJ RHONE_ <br /> TYPE OF SEPTIC WOW: NEW MSTAUATON RdANVADDITION❑ DESTRUCTION❑ <br /> I� IND SEPTAL SYSTEM PERMITTED IF FVBUC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEAL TESTI.I 1 I HOW MANY <br /> INSTALLATION WILL SEINE WSIDENCE❑ COMMERCOK❑ OTHER y! <br /> NUMBER OF LIVING UNITS:_NUMBER OF REMOOMSIN/.,80t OF EMPLOYEES: <br /> CHA OF SOIL TO A DEPTH OF 3 FEET' A /C�..LI.t PITIISSUMP,S,O,,ILL CHARACTER.- � ICL-1^� WATER TABLE DEPTH ZO <br /> i SE TRAP E]TYpQMFG Cq�_ :+Lk--A R` CAPACITY ll MJ.COMPARTMENTS <br /> PKO TREATMENT PLANT❑ INSTANCE TO NEAREST: WEuLdie� FOUNDATION_ PROPERTY UNE _ <br /> UFT STATION❑ S E TYPE OF PUMP .[�SAND OB SEPARATOR IENCLOSEO SY67EMI <br /> LEA.."UNE �No.A LENGTH OF MEG `�D'�/L• If, DISTANCE TO NEABEST:WELL/C90 FOUNDATION,Q_PROPERTY UNE= <br /> r FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UHE_ <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL �j(,�/� FOUNDATION PROPERTY LINE_ <br /> ® <br /> SADE RTH�TS DEpSCM -�L I NUMBER I WGTANCE TO NEAREST:WELD FOUNDATION IM F PROPERTY LINE I <br /> SUMPS WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE_ <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WFLLFOUNDATION PROPERTY UNE__ <br /> t HEREBY CUITIFY THAT 1 HAVE PREPARED THIS A ATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN"AWN COUNTY ORDINANCES AND STATE LAWS <br /> AND REGULATIONS OF THE SAN"AWN COUNTY.HOME OWNER ORM ED AGENT'S SIANANRE CERTIFIES THE FOLLOWING:')CERTIFY THAT IN THE PERFORMANCE OF THE WOR <br /> THIS pEISAFT IS ISSUED.T SHALL NOT EMFt ANY N IN SUCH A ERAS TO BECOME SMIJMA <br /> ECT TO Wp1KMAN'S COMPENSATION LAWS OF CALFON ' CONTRACTOR <br /> SUB-C/HiTR'LC SIG QUIFF /E FOLLO :T CERTIFY /4A IN THE PFRTowANCE OF THE WOR(FOR WHICH TMS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS <br /> WOIRTA COMPS A N O ORMA' tH A MUS 24 MuFLS IN ADVANCE FOR ALL REOURED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> Z <br /> SIGNED TRIS: DATE:_ <br /> PLOT PLAN RMAW TO SCALD SCALE.*IJ <br /> I.NAMES OF STREETS OR TOADS TO OR BOUNCING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM or'PF <br /> 1. oknLRA OF THE PROPERTY.WITH DB./ENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL NI OSYSFON <br /> ixI4cNMNED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, <br /> f.LOCATION OF WELLS VAT SOH N4INV8 OF ONE HUNDRED <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,WYVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. <br /> ZU <br /> C.j/�J''/ .... <br /> l� <br /> �S <br /> Aq <br /> FOR DEPARTMENT USE ONLY <br /> DATE- <br /> Y♦ /A/pg'(CATION ACCEPTED BY Q J <br /> / ATX OR SUMP WiSPECTON eY DATE / �1K W SPECTRIN B i <br /> �AD�!!O ADDITIONAL COMMENTS:—!O 5 <br /> ADJ FACI <br /> ACCOVNHNO ONLY: - <br /> KJKASN RECEIVED SY DATE SR/PERMIT NiNSER INVOICE/ <br /> K CODE FEE INFO AMOUNT REMITTED J <br /> SSM 2 <br /> Pub.Health Sam.-Enviro.174(3196) L/ <br />