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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4%co ENVIRONMENTAL HEALTH ENVISION J N,CA 95201X88 P.O, BOX 388, 304 EAST WERER•AVENUE, 8'f'OCKTO (2001488-3420 COPY 4- ADN-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE 18-SUED (Complete In Trlpkata) ' APPLICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WFTH SAN JOAOVIN COUNTY DEVELOPMENT TrTLE,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE@,ENVIRONMENTAL HEALTH DIVISION. w_ _ CITY LOT 81ZE JOB AODRESeIOn APNI OWNER'S NAME /W Fj ADDRE88 PHONE CONTRACTORi I i /� ADDRESS Z2tLICI�,�„PHONE - BUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF SEPTIC WORK! NEW INSTALLATION REPAIMADDITION ❑ DESTRUCTION❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEEL OF BUILDEND.1 PFRC TESTI%)1 1 HOW MANY ApjAmffon f INSTALLATION WILL SMVE: RESIDENCE❑ COMMERCIAL El OTHER❑ NUMBER OF LIVING UNITS: NUMIeLn OF vFDROOMS, �718UMP SOIL C�HARF P OYEES!T u T 9LE DEPfH CHARACTER OF SOIL TO A DEPTH OF 3 FEET: D j SEPTIC TA14KIOPEASE TRAP ❑TVpElMFG CAPACITY - NO.COMPARTMENTS PKG TREATMENT PLANT E7 DISTANCE TO NTMFST: WELL i-- FOUNOATION�7— PROPERTY .'S��- LIFT STATION❑ BRF TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACIING UNE ❑ ND.A LENGTH OF LINES /�'f DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER RTD WIDtH2—LFNGTH'7�7 �EPTH��DISTANCE TO NEAREST:WEl.1,f�FOUNDATION PROPERTY LINE��^ MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY LINE ` SEEPAGE PITS 11 DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE r SUMPS ❑%MOTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE 1 HERESY CERTIFY THAT I HAVE PREPARED TH10 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AOENT'8 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE wonK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A8 TO BECOME SUBJECT TO WOIKMAN'8 COMPfNBATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,18HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X _� TITLE• ��?- ��r' --DATE' PLOT PLAN(DRAW TO SCALE)SCALE '(o 1. NAMES OF STRFETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE eEYVADE 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 WELL@ WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXS. THE PROPERTY OR ADJOINING PROPERTY. .... _ - .. .. �.. _ .. .. .. . k r . J 1 ..Pd I , .—i_ ... :............ .. .......... .. I G . I .....:. - ..., .. .. ...... .. .. .. .. .. .. .. .. I [ i .. ., .. ..;,... .. .. _ .. .. I -- � =. �F . SEP . ur�i spm! :.....:.....:.....SAN�lOAi} .Ni'A�NEI►LYFi�S)(7P......., -- -. -- —= FOR DEPARTMENT USE ONLY r l /1 /1 ."QRS`,•-" ,"' °°°'�R':.. -�:�:t.;,cAx's �'. ., ti,<' . F �.,.s ryA,fSEA:,, � •,�� APPUCATION ACCEPTED BY 1l V V - ' TANK,PIT OR BUMP INSPECT( 1 Y/�p ,//1 DATE ! n1 _FINAL INSPECTION BY DATE ADDITIONALCOMMENTS:. ' 7T1.1')� �' I vv4Z, r ' ACCOUNTING ONLY: AID0 FAC# PE CODE TEE INFO AMOUNT REM(I TED HEC CASH RECEIVED BY DATE SR I PERMIT NUMBER INVOICE# - �" 05� GI Pub.Health Serv,-Enviro.174(3198) I ! L