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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C!(,) ENVIRONMENTAL HEALTH DIVISION P,O. BOX 988, 304 EAST WEBER-AVEWE, STOCKTON, CA 95201388 (209) 488-3420 MOM•11 FUMUABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUES (GNIpMb ill TrlpUefal APPLICATICN IB HEPEBY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONBTMICT AND/OR INSTALL THE WORC DESCRIBED. THIS APP1CATgN t8 MADE IN COMPLIANCE WITH BAN JOADM COUNTY DEVELoPAva TITLE, CHMTER 9.1110.3 ANO THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERYIICES, ENVIRONMENTAL HEALTH DIVISION, JOB ADDREBBroR,JAP//L9 N/ oC�J'SF .� qI7 t �197T� Cm AZR L LOT SIZE.�G OWNER'S NAME eje* T 1124C*P o/L6CN ADDRESS y5y,t 0:�rll�l F-ltf> PHONE CONTRACTOR - F,NirlAifi ADDRESS j% LIC# A: PHONE L f`- tiM CONTRACTOR A/ r ✓6c 'ter- ADDRESS >0 XA TIIZ& • o VC#,4k:'J�.�2 PHONE a 7 ]r TYPE Ok fEPRC WORK: NEW INBTALLAnOM ❑ ANO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER 18 AV/ REPAIwAodnoN ❑ WRNIN 200 FEET OF But DING DUTRucnoN I`N P31C TESTUI I I HOW MANY Apptomton # INtTALUATON WILL smut: REBIDENCE� COMMERCIAL ❑ OTHER ❑ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ NOMSER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/BUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑ TYPEIMFO CAPACITY �rc[% NO, COMPARTMENTS o2 PK0 TREATMENT PLANT DISTANCE TO NEAREST: WELL�GT3� �— FOUNDATION 6�7 PNOPEM UNE UFT STATION ❑ , rrzr. TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEMA _ LEACHING LINE ljl NO. St LENGTH OF LINES 'F: DISTANCE TO NEAREST: WELL FOUNDATION Il q PROPERTY UNE RLTER BED ❑ WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE MOUNDS) ❑ WIDTH LENGTH DEPTH DISTANCETO NEAREST: WELLFOUNDATION PROPERTY LME fEEPACE PITS ❑ DEPTH BRE NUMBER DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE SUMPS ❑ WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑ WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS, AND RULER ANO REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFYTHAT M THE PERFORMANCE OF THE WOPK FOR WHICH THIS PERMIT HI ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR BUB -CONTRACTING SIGNATURE CERTIFIES THE FOLLOWNN3: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORLMANTI COMPENSATION LAWS OF CAUFORNIA.' THE APPLICANT MUST CALL 24 HOLM IN ADVANCE FOR ALL MGUIRED INSMTIONS, COMPLETE DRAWING BELOW. TRUE: �� DATE:�T to 4. LOCATION OF HOUSE SEWAGE DI SPOSAL SYSTEM OR PROPOSED E%PANHION OF SEWAGE DISPOSAL SYSTEMS, 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, ON THE PROPERTY OR ADJOINING PROPERTY. f�FOR DEPARTMBIT VEE ONLY APPLICATION ACCEPTED BY / [W,-%�'t�`�n �'�l•! ) 7 (,, ^1 DATE:�� TANK, PT OR BUMP INSPECTION BVG'i G ' 1 L'I'�� ATE"T �Y I / FINAL INSPECTION ADDITIO NAL COMMENTS: ACCOUNTING ONLY: AID/ FAC/ PE COD FEE INFO AMOUNT REMITTED CNECK/ICASH RECEIVED BY Pub. Health Serv. - Envlro. 174 (3/96) DATE fll l PBMT NVRam INVOICE f Pub. Health Serv. - Envlro. 174 (3/96)