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' Icamplall in Triplirata) APPLICATION 16 HEREBY MADE TD THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE VAT"SAN JOAQUIN COLW Y DEVELOPMENT �TITLE,CH R 9-1110.3 AND THE STANDARDS OF SAN�'�JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ApORESSIOR APNIF / 6a 2-� �`-"r° ti+'Q� �,( ,C'ITIY ME- PHONE- CONTRACTOR Ll LO'l SIZE ' OWNER'S NAME)(—A O ADDRESS !4q-&. Il t�lAD—lQyV RING PHONE-CONTRACTOR `'� �- ADORE68 "'FC.I`P�i 1....��JNL`»c� UCM PHONE BUB CONTRACTOR ADDRESS UC# P!10NE1 TYPE OF SEPTIC WORK: NEW INST TION❑ REPAIFUADDITION ❑ DESTRUCTION❑ /� (NO SEPTIC SYSTEM PERMITTED IF PUBLIC 9 R IS AVAILABLE WITHIN 200 FEET OF SUILDING.I PERC TEST(e)I IHOW MANY / 2— ApPS0N0n'RA S a /-3`IIID G. INSTALLATION WALL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER 11 NUMBER OF)MNG UNITS: NUMBS) F BEDROOMS: NUMBER OF EMPLOYEE$: CHARACTER OF SOIL TO A DEPTH OF 3 FEE?: PITfSUMP SOIL CHARACTER; WATER TABLE DEPTH C�3 ' SEPTIC TANWOREASE TRAP ❑TYPEiFAR�IG CAPACIT-t - NO.COMPARTMENTS PKO TREATM@1T PLANT® DISTANCE TO NEA REST: WELL FOUNDATION PROPERTY UNE UFT STATION❑ SIZE TYPi.OF PUMP SAND OIL SEPARATOR JENCL40SEO SYSTEM) LEACHING UNE ❑ NO.m LENGTH OF I INES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE FILTER RED ❑WIDTHGTlA_— DEPTH DISTANCE TO NEAREST:WELL FOUNDATION M- PERTY UNE i]WID MOUNDED TH GTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE N SEEPAGE PITS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST;WELL FOUNDATION PROPERTY UNE C-' Stomps 0 WIDTH LENGTH _DEFTH-_ _DISTANCE TO NEAREST:WELLm FOUNDATION PROPERTY UNE DISPOSAL PONDS i]WIDTH LENGTH _DEPTH DISTANCE TO NEAREST:WELL _FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT(HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 4AN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OFTHE SAN JOAQUINCOUNly.HOME OWNEROR LICENSED AGENT'S SIGNATURE CERTIFIES THEFOLLOWANG:'I CERTIFYTHATINTHE PERFORMANCE Of TIIEWORKFORWHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY A lY PERSON IN SUCH A MANNER AS TO BECOME SUBJECTTD WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THEFOLLOWING:'I CEKTIFYTH,4T IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOF%KMAN'B COMPENSATION LAWS OF CALIFORNIA.' TN CANT MUCT CALL 24 HOURS IN ADVANCE FOR ALL REOURED INSPECTIONS. COMPLETE DRAWING BELOW. SIGNED X �/V r� TITLE:_ dDATE; dJ7—2rra 2!5- PLOT PLAIN(DRAW TO SCALf.)SCALE -10 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROFOSED 2. OUTLINE OF THE PROPERTY,WITH OIMENMO NS AND NORTH DIRECTION, EXPANSION Of SEWAGE DISPOSAL SYSTEMS- 3, DIMEN81ONED 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 Oft ADJOINING .. .... .....:.... ..Fr�4'�I' .' RDA : ..:... .........: ... . ;... . .. ..... ............ : .... ::. n...... p. .. y'y`� i� {} q Q�°, ....... :+(' .. ... ................. .. VV 1V V,-l�Jd. ....... _ U. �•:.}.IEAi,61. ENVIRON,nEl� HEALTH :. TMENT USE ONLY _ APPLICATION ACCEPTED BY DATE; LA AREA:... r ' TANK,PIT OR SUMP IN°.PECTION BY DATE 1 1 FINAL INSPECTION BY DATE - 1 'f DD ,{ AITIONAL COMMEPfT3: ' ACCOUF TMG ONLY: ATOM FACM PE CODE_ _ AMOUNT REMITTED CHECK0IGASH RECHVm aY DATE SR 1 PERMIT NUINBI3S INVOICE0