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'N JOAQUIN COUNTY PUBLIC HEALTH SERVICES NVIRONMENTAL HEALTH-'DIVISIO T ^ Tr > "!tuICF3 �q�,tL��I S iJI .. P.O.POBOX 388 304 EAST VIE 6 468.AVENUE,2oIRV S10C�C�91V u '7 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUEB ...'r_s�+--i-,_ . (Complete In Triplicate) APPLICATION 19 HEREBY MADE TO THE BAN JOAGUM COUNTY FOR A PERM?TO CONSTRICT AND/OR INS4%E'1HE WORK DESCRIBED. THIS APPLICATION 19 MADE W COMPLIANCE WITH AN JOAQUIN COUNTY DEVELOPMENT TRUE, J/C[`HAPTER 9B+-1110.3/AND THE STANDARDS OF SAN JOA'OJ�pINyC/$1�N1Y PUBLIC HEALTH BERM �/NVIIKINMENTAL HEALTH DIVISION. L JOB ADDRES6/OR AM# / / 4/(J L�j, ��VL(Lii/L,LJQ ,-,!� 'l`-✓' CNy � LOT SIZEJ�+ 7 OWNER'S NAM /( ,/may.., J ADDRESS , ��J/`P�{IONE Z � CONTRACTOR /VI(/ !�vADDRESS IZI C•C/ILCK E� y �.VF'C— HCI I(,(j pIpNE SUBCONTRACTOR ADDRESS UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION REPNWADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PE1C TESTNI I I HOW MANY AppilmOon# INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCI OTHER ❑ NUMBER OF"NO UNITS:_ NUMBER OF SEDRGOMS: NUMBER OF EMPLOYEES: CH OF SOIL TO A DEPTH OF 3 FEET D SAG RT/SUMP SOIL CHARACTE WATER TABLE DEPTH lL5Y9 TYPEIW P PPC T TMENT PLANTR❑ DISTANCE TO NEEM ' WELL CAPACITY FOUNDATION L NO.PROPERTY LINE L / LET STATION❑ S1ZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED 9YST EMI LEACHING LINE ❑ NO.6 LENGTH OF LINES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER RED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE MOUNDED aYY�❑JhhW WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SEEPAGE PTS y-uev1H�s, SIZE �i J NUMBERDISTANCE TO NEAREST:WELL�FOUNDAT40N�L7 / PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE I HERESY CERTIFY THAT 1 HAVE PRE THIS APPLICATION AND THAT T E kVORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANDREOULATION FT NJO GUIN O .HOME OWNER OR LICE ED ENT'S SIGNATURE CERTIFIES THE FOLLOWINI:9CERTIFYTHAT IN THE PERFORMANCE OF THEW@K FORWHKIH T PE lot 0, SH L N T EM OY PERSON IN SUCH A MANEld AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOIWIA.• CONTRACTOR'S HIRING OR e-CONTRA 1 0 6 ATU CE IR THE LLOWIN RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO IKMAN'S C PE TI O FO I ' THE CAN MUST ALL 24 HOURS IN ADVANCE FOR ALL REam INSPECTIONS. COMPETE DMWING BELOW. a BIG D% TITLE:_ - PATE: I ' '2 IS POT PAN IDRAW TO SCALEI SCALE 'le 1. NAMES OF STREETS OR ROADS HE ST T OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PIOPoSED 2. OUTLINE OF THE PROPERTY,WITH DI NSI NS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOBAL SYSTEMS, 3. DIMENSIONED 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, n 1 THE PIOPRTY OR ADJOINING PROPERTY. J jr ytiL 173 - Oq". �. LA 7IL FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �� DATE: II AREA: Z I` C RNSPCTIOH BY _ DATE /✓ (NAL INSPECTION BY DATE / `` ADIXTIO C MENTS. Qmru ACCOUNTING ONLY: AID/ FAC# PE CODE FEE Iwo AMOUNT RRmI O CIIEC CASH RECEIVED BY DATE M f PERMITNUMIFM INVOICE# Pub,Health Sew.-Enviro.174(3/96)