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{CampieU b i/�tscaU) Application is hereby made to the San Joaquin County for a permit to construct and/or instal the +cork described. This applfcation is made in compliance with San Joaquin County Development Title, Chapter 9-1110.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. Job Address/or APNK qZQ /y! Z/11,A�/ Aiz e, City�?�ClG j a�J lot Slze Z R 1G �� l Owner's Nana Com./+�I S;1j C �pL 1 SM,Tt/ Address 41q // /I/ Z, ,A,tiJ /QtJ� �1 y�(Gi PhaneytiP?- 7/�9 Contractor4 ' 2 Address Lic# Phone lSub Contractor Address Lich Phone TYPE OF SEPTIC WORK: NEW INSTALLATION(I REPAIR(ADOITION(j pESTRUCTIDN, -1 __ PERC TERrisi l I Haw Daae; (NO SEPTIC SYSTEM PERNIITED 1F PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) Lead Use/.pMiaatiaa f installation wilt serve: Residence Commerciat other Numbar of living unitat Nunt»r of bedroomar Number of amployeear Character of soft to a depth of 3 feet: Plt/Sump Soil Character. _ hater Table Depth SEPTIC TANKIBN£ASE TRAP (I Type/mfe Capacity- No. Compartments PXG TREATMENT PLANT i ) Distance to nearest: Well Foundation Property line LIFT STATION❑ Size Type of Pump Sand oil Separator (enclosed system) ^� IfACHINS LINE n No. 8 length of tines Distance to Nearest: Welt_— Foundation Property Lirr. FILTER BED ❑ width Length Depth of " Well . _ Foundation Property Line MOUNDED l) Width Length_ Depth " " WeIL Foundation Property Line SEEPAGE PITS U Depth Size Number Wetl Foundation Property Line SUMPS 11 Width Length Depth " " Well Foundation Property Line DISPOSAL PONDS i) Width Length Depth " " Well Foundation Property Line I hereby certify that I have prepared this application and that the work will be (none in accordance with San Joaquin County Ordinances and State Laws, and Rules and Regulations of the San Joaquin County. Hoare owner or licensed agent's signature certifies the following : "I certify that in the performance of the work for wick this permit is issued, I shall not eaploy any person in such a reamer as to become subject to workman's compensation taws of Cs!ifornia." Contractor's hiring or sub-contracting signature certifies the following. "I certify that in the performance of the work for which this permit is issued, I shall emptoy persons subject to workmen's compensation laws of California." TM appGcaat mw ealt 24 twors to a�vaaa far sll ragoEra� aPeotioaa. Canpletc drawing below. Signed _ Title: Dater PLOT PLAN (Draw to Scale) Scale " to 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or 2. Outline of the property, with dimensions and North direction. proposed expansion of sewage disposal systems. 3. Dimensioned outlines end Location of all exfstinir and proposed 5. Location of wells within radius of 150 ft. on structures, Including covered arena such as patios, driveways, the property or adjoining property. and Walks. u L?A C H A4 Tl ':i fir; i : kii FOR DEPARTMENT USE ONLY f Application Accepted by Date• T�Are _ Tank, Pit or Sump Inspection by Date / / Final Inspection b = Date¢ Additional Comments: 11 •Mnf.15Y Y.rn nLl Y. ....u ....L