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APPLICATION FOR LIMIO WA (MIT <br /> SAN JOAOU4N-COUNTY-PUBLIC HEALTH SERVICES ? <br /> ENVIRONMENTAL HEALTH DIVISION <br /> j 304 EAST WESER AVENUE,STOCKTON,CA 95202 <br /> 1i (209)468-3420 <br /> ROWREFUNDARIE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> iCempMIE fn Triprmatff <br /> APPLICATION 18 HEREBY MADE TO THE BAN MAQUIN COUNTY FOR A PERMITTO CONSTRUCT ANDUOR INSTALL THE WORK DESCRIBED.THIS APPLICATION I BAN <br /> 2f JOAOVIN COUNTY DEVELoPmEN7 TITLE,CHAPTER 9-1110.3 AND THE STANOAROU OF S JOAONN COUNTY PUBLIC HEALTH B/ERVRCEB,Ewr%oNMEM L d <br /> S. <br /> / <br /> 1 JOB ADORESSUOR APNR r 6)I `— v / CITTYY�� �L— 2 061AI ) LOT SIZE ^J <br /> 4Y OW?IEA'S NAME _ h^ AdME59 (`LV �/ �'Y' �J l_/Ul�t•L 1/V���iT70NE �'�( <br /> CONTRACTOR ADDRESS LK:I PHONE <br /> SUS CONTRACTOR ADDRESS LIC/ PHONE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIFVADbITION❑ DESIRUCHON <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLUC 6EWER IS AVAILABLE WITHIN 700 FEET OF BUILDINO.1 FERC TTAT[UI L I NOW MANY —} <br /> + 1�t ClAPpEoEtlon/ C'�1 <br /> J INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL 1.1 OTHER Cl v <br /> _�. NUMBER OF UVINO UNITS: NUMBER OF SEDNOOMS: NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOS,TO A DEPTH OF S FEET: PTTMJMP SOIL CHARACTER: WATER TABLE DEPTH_ <br /> SEPTIC TARKJOREAfE TRAP ❑TYPEUMFD CAPACITY NO.COMPARTMENTS A <br /> I <br /> Y /ICO T11FJIliMENT PLANT❑ DISTANCE TO NEMEfi: WELL FOUNDATION PROPERTY LINE <br /> �i LIFT STATION❑ 512E TYPE OF PUMP E-T{�—SAND OIL SEPARATOR[ENCLOSED SYSTEM? -y <br /> LEACHING UNE UU�y <br /> �PE..�NO,i LENGTH OF ONES S l v DISTANCE TO NEAREST:WELLMUNDATbN�PROPERTY NNE l! <br /> FILTER BED LJ WOTN LENGTH r DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> MOUNDED C1 WIDTH LENGTH DrPFII DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY NNE <br /> I SEEPAGE PIT/ i O— SQE NUMSER-3—DISTANCE TO NEAREST:WELL FOUNDATION PROPERTYUNE <br /> SUMPS ❑WIDTH LENGTH DEPTH INSTANCE TO NEAREUT:WETS FOUNDATION PROPERTY LONE <br /> DISPOSAL PONof [3 WIDTH LLNOtH DEPTH DISTANCE TO NEAPFSTI WEJ FOUNDATION PROPERTY LINE C <br /> I HEREBY CERTIFYTHAT 1 HAVE PREPARED THIS APPLICATION AND THATTHE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTYORDINANCE9 AND STATE LAWS,AND RULES <br /> ANOREaULAT1om OFTHE BANJOAOUINCOUNTY.ROME OWNER OR UCENSEO AGENT'S SIDNATVHECEKTIFIERTHErOLLOWWa:TCERTIFYTHAT INTHEPERFORMANCEOFTHEWOMFORWHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO SECOME BU&iECT TO WDIKMAN^B COMPENSATION LAWS OF CALIFORNIA CONTRACTOR'S HIRMD ORBU&coC <br /> IS <br /> 1VUED,I SHALL EMPLOY <br /> WoMEmANNi/UICTINO BIaNATURE TgN�CERI'IFIECB THE SII FOLLOWING;HE APPLICANT MUST CALL 24 PERFORMANCE <br /> d ADVANCE FOR ALL REQUIRED INSFEC ONE,IC COMPLETE DRAVANG 11MOW.`�T•,NyB BUSJECT 70 <br /> 1 CUA/ <br /> , (f <br /> �# BRINED x �Y`' TITLE: G` !✓ p S DATE: <br /> t ROT MAN[DRAW TO SCALEI BCAtJr 'to <br /> 1.NAMES OF BTPEETB ORROADS NEAREST TO OR BOUNDING THE PROPERLY. 4.LOCATION OF FIOUSE SEWAGE DISPGBAL SYSTEM OR PROPOSED <br /> 2-OUTLINE OF THE PROPERTY.YNTH DIMENSIONS AND NORTH DIRECTION. ExPANamoN OF SEWAGE DISPOSAL SYSTEMS. <br /> I^ 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES 6 LOCATION OF WELB WITHIN RADIUS OF ONE HUNDRED FIFTY R ON <br /> e f <br /> INCLUDING COVERED MEAS DUCH AB PAT08 DRIVEWAYS AND WALKS- THE PROPERTY OR A13JOlMNO PROPERTY <br /> !i[ I . . ...v ... .,,...... ... ... <br /> f , <br /> f - .. ..L... .... <br /> .:...... ...�:... ... ...... ... I ...i,. <br /> -- i• i ; i E <br /> ....:.... Z�..r, i ... . ..., .. .... <br /> . <br /> 2. <br /> . <br /> .� <br /> ti . . � <br /> 3 . <br /> a.... .. <br /> f <br /> U <br /> .. ..... 0.... a <br /> GI la }5� ... <br /> ............ ..... ...... <br /> ...... ....... <br /> ...... ..... <br /> .... ........... ............. <br /> ... ....... .............. .. ..... ...... <br /> ... . .... ........... ... ........... <br /> ............ <br /> t S < FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED MY l U 1 DATE: �'l IT-PJ AREA, [ <br /> + TANK,PIT OR SUMP INSPECTION BY DATE I I FINAL INSPECTION MY DATEf ! i <br /> MDrrlOM COMMENTS: <br /> ACCOUMDNO ONLY: ACDF FAC/ <br /> PECODE FEE INFO AMOUNT REMITTED CHECK/ICASH RECEIVED BY DAT Sn U PEOJST NUMBER INVOICE/ <br /> 31 yl <br /> :0lqqqo <br /> 4 <br /> A Pub.Heakh Sere.•Errvjro.174(3196) <br />