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SAN JOA❑UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PA BOX 388,904 EAST WEBER AVENUE,STOCKTON.CA 95Mt-W <br /> 12091 468-2420 <br /> P1011.REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICBmplAty iR TriPliuUl <br /> APPLICATION IS HEREBY MADE To THE BAN MAMON COUNTY FOR A PERMIT TO CONSTRUCT ANONIR MaTALL THE V00W OESCRINED.TMS APPLICATION 18 MADE IN COMPLIANCE YATH BAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER <br /> ,B-I 110.$ANO THE STANOAROFI OF SAM JOA00NN COUNTY PUBLIC HEALTH SEFIOCE6.ENVIRONMENTIMSI <br /> AL HEALTH OON. <br /> Job ADDRE6WR APNI Q3 �/�/L 5 G`I"L �✓ CITY ^ e-- LOT SIZE�Z <br /> ��V 2 <br /> OWNER'S NAME—Zj( O .'l C- / AOOI%SS-_—.��� 7 Jr PHONE 9'LiL5�'k5— <br /> CONTRACTOR AODRESC—.-_— LICS PHONE <br /> SUBCONTRACTOR_,", AIMPLSS_ ��o. /�V �.A%-&],,4 J i:> <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ' REPAIRIAOtNTION❑ DEATAuCTION❑ <br /> CTO SEPTIC SY6TEM P(RMTTTEO IF WOLIC SEWER IS AVAII ASLE WITHIN 20O FfE I Of RUIU)INC.1 PALO TESTDI I I NOW MANY <br /> APPSA%tlen. T� <br /> INSTALLATION WILL SERVE RESIDENCE COMMERCIAL❑ OTHER 0 <br /> WAMF I OF LIVING UNITS:_-NLKA391 OF SEDROO Ma;4_NWRW OF 6NPLOYEES <br /> CHARACTER OF SOIL TO A DEPTH of 3 FEET: T(SUMP SOIL CHAMCTF.ft:�f_ WATER TABLE DEPTH <br /> FPIG <br /> 6TIC TANKRFAGE TRAP 0TWSUFQ �� CAPACITN' /(�C/J� NO.COMPARTMENTS .29 ` <br /> PKO TREATMENT PLANT 0 DISTANCE TO NEARFAT: WELL I��r <br /> OIL FOUNOATIONPROPERTY UNE.12 I <br /> UFT STATION Cl SIZE TYPE DF PUMP 5 O !:EPARATOR IFNCI OSEO SYSTEM) <br /> LINES � <br /> fT <br /> LEACHING UNE IJq No.iLENGTH OF NES �/f/L/ Fr DISTPNCE IO NEA'tfST:L1FItr(�fOUNOA7lON O PROPEITTY UTNE <br /> FILTER SED ❑WIDT)I LENGTH OEP1H_____DISTAt:CE TO NEAREST:WELLFOUNDATION PTA7PERTY UNE <br /> MOUNDED LT 1MDTH LENGTH^,- DEPTH DISTANCE TO NFAREST:WELL FOUNDATION PROPERTY UNE <br /> SEEPAGE RTS ❑DEPTH SIZE _NUMBER DIRTANCE TO NFAREST:WELLFOUNDATION PROPERTY LINE <br /> BUMPS ❑T••TI WIOTH LENGTH—DEPTH OISTANCE TO NEAREST:W 4( <br /> EILFOUNDATION PROITY UNE <br /> DISPOSAL PGAIM LJ WA)TN LENGTH _DEPTH _OISTANC.E TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> 1 HEREBY CERTIFY THAI I HAVE PREPARED THIS APPLK:ATICN AND THAT THE WORK WILL BE OONE IN ACCORDANCE WITH SAN bAUUIN COUNTY ORDINANCES AND STATE LAWS.AND RHES <br /> AND REGULATIONS OF T HE BAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERT IF IES THE fOLLOWN0:-1 C ERTWYTHAT INTHE KPIFORMANCE OF THEINGW FORWHICH <br /> TIRE PERMIT IS ISSUED,1%HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJFCT TO WOW MAN'S COMPENSATION LAWS OFCALIFORNIA' CONTRACTOR'S HNNO DR <br /> SUB-CONTFU CTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE Of TOE WOW FOR W WCH THIS PERMIT IS ISSUED,1 SHALL EMPIAY PERSONS 6UB.IECT TO <br /> VJDFSOAAN'S COM/PEE NNSATION LAWS CF CA FOFWIA.-THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOXAAED INAPFCTIONB.COMPLETE ORAWND BELOW. <br /> SIGNED x // ' _TTi LE: ��� JL'C DATE: <br /> T/ PLOT PLAN IDMW TO SCALE)SCALE ___._ <br /> I.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. POE.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM ON PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMS. ✓. <br /> 0.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTUREC. 6.LOCATION OF WELLS WITND <br /> MIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> tNCLUONG COVERED ARFA6 SUCH AS PATIOS,ORIVEWAY6,ANO WALKS. THE PROPERTY OR ADJOINING PROPFFITY. <br /> �A t L I k f ? <br /> U I <br /> p <br /> FOR OEPARTME'T1T USE ONLY <br /> APPLICATION ACCEPTED BY—__.�.�._. DATE: <br /> TANK,PPT OR SUMP tNSFFCrIOrT Ul _OA TF_ FINAL)NSPFCTION BY DATE V)� <br /> ADDITIONAL COMMENTS:M <br /> ACCOUNTNG ONLY: I ATOP —LFACP <br /> PICODE FEE INTO AMOUNT."0TFG CI.EC (CASH RECUVTO BY OAIE AR/PON"NUMBER INVOICE <br /> E - G D3 3 s <br /> P,)h.HeaJth Se,-EGviro.174(3196) <br />