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SAIu OADUIN COUNTY PUBLIC HEALTH SERVICES 'ENVIRONMENTAL HEALTH DIVISION t 1 P.O. BOX 3W8 u4 EAST WEBERMENUE, STOCKTON, CA ya201�88 (2091460-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CompletB In Triplicsto) APPLICATION 18 HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMrr TO CONSTRUCT AND/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 ADDRES$1oR APN/ ' GITY LOT SIZE OWNER'S NAME +- ADDRESSTb CiNJ�ti jpLo PHONE CONTRACTOT-- Com`LU�J_ADORESS �L �Aa-' LICA PHONE SUB CONTRACTOR JX •�/ �� ADORESs PHONE / TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDiTION ❑ DESTRUCTION❑ ANO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TEST191 I I HOW MANY Applloodon,T INSTALLATION WILL SERVE: RESIDENCE 0 COMMERCIAL❑ OTHER ❑ �— NUMBER OF LI1AN0 UNI78; ! NUMBER OF BEDROOMS: NIAVIIIER OF EMPLOYEES: ) CHARACTER OF SOIL TO A DEPTH OF 3 FEET: D PITlSUMP SOIL CHARACTER: WATER TABLE DEPTH - CAPACITY ND.COMPARTMENTS . I SEPTIC TANKIORFASE TRAP �TYPE/MFG j PKO TREATMENT PLANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) 1 _ f Fri LEACHING LINE NO.Si LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNOATION PROPERTY LINE FILTER BED 13 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE To NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE RTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WFLL��FOUNDATiON ! PROPERTY LINET� SUMPS V1 WiD7H DEPTH��DISTANCE TO NEAREST:WELLFOUNDATIONPROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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:"I CERTIFYTHAT INTHE PERFORMANCE OF THE WORK FORWHICH I THIS PERMIT IS ISSUED,1 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOWCMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOVR8 IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW, SIGNED X TITLE: --'-eJ DATE• PLOT PLAN(DRAW TO SCALE)SCALE T. 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. .... __ .. : ... �1 . Z. .......... T .. . . .. :, . ...... ... -. RLLy ... .. .19.9$ _ d c 3iJrra .. A Lry SEv EN1t1Hp .. �.r•r€acres�vsrotv.. .. ... ..... . >.....:. .. FOR'DfFARYMENT-fiBERNLY APPLICATION ACCEPTED BY DATE: TANK,PIT OR SUMP INSPECTION BY DATE J ! FINAL INSPECTION BY DATE ADDITIONAL COMMENTS: ACCOUNTING ONLY: AiDJ1 FAC# PE CODE FEE INTO AMOUNT REMI1 TED CHECK? ASH RECEIVED BY DATE SR!PERMIT NUMBER INVOICE! Pub.Health Serv.-Enviro.174(3/96)