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F"-�IJOAOUIN COUNTY PUBLIC HEALTH SERVICES r <br />ENVIRONMENTAL HEALTH DIVISION , i`, <br />P,O, 80X 388.304 EAST WEBER AANUE, S OA l - <br />(2691 468.3420.. <br />IL <br />NON•REFUNDARLE PERMIT EXPIRES 1 YEAR Fi10M DATE � t �]► <br />(Complrte In TTipikettl) <br />i APPLICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AN !OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9- 1110.3 AND THE STANDARDS OF SAN JOA UIN,COUNTY PUBLIC HEALTH SER�VIrC�E�S, ENVIRONMENTAL HEALTH DIVISroN. <br />,�. JOB ADDREBSIOR AFC - 'y n �t... �t� -T� ..- "�',y � .,�• CITY— • S��Y _ LOT 812E <br />I OWNER'S NAME An Q. a1Y �� . wnn — `J91�YA! !�}' l .� ... i� 1 i ds <br />Sun CONTRACTOR n ADDRESS <br />*151 -0 - I <br />PHONE <br />"TYPE OF SEPTIC WORK: 1N7 <br />INSTA(LATION,jq7zzz REPAIRIADO1TION ❑ DESTRUCTION ❑ <br />,MO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IB AVAILABLE WITHIN 200 FEET OF BUILDING.) FERC TESTIQ 1 1 HOW MANY <br />- APPSeetlon / <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL OTHER•❑"" -' r-- � <br />,;INSTALLATION <br />OF LIVING VMTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEE8 -18 I %]o L PLO Il1Vlr y <br />f CHARACTER OF SOIL TO A DEPTH OF J FEET: PITISUUS D <br />MP SOIL CHARACTER: WATER TABEPTH <br />:SEPTIC iANK10HEASE TRAP (TYPE/MFG_ s: _ _ _,_ CAPACNv _ tNO. COMPARTMENTS <br />PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br />LIFT STATIOFI ❑ B TYPE OFUMP SAND OIL SEPARATOR (ENCLOSED SYBTEMI. ! ' <br />LEACHING UNE D. N DISTANCE TO NEAREST: WELL�� FOUNDATION_ PROPERTY UNE _ <br />FILTER BED, ❑ WIDTH LENGTH____jVtjFTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE <br />MOUNDED ❑ WIDTHLENGTH DEPTH DISTANCE TO NEAREST! WELLFOUNDATION PROPERTY UNE <br />SEWAGE PITS 13 DEPTH SIZE - NUMBER DISTANCE TO NEAREST; WELL FOUNDATION PROPERTY UNE <br />SUMPS 11 MOTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br />DISPOSAL PONDS ❑ VADTH LENGTH DEPTH DISTANCE TO NEAREST: WELLFOUNDATIONPROPERTY UNE <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS. AND RULES <br />AND REGULATIONS OF THE SAN JOAOUINCOUNTY. HOMEOWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING; 'ICERTIFYTHAT IN THE PERFORMANCE OF THE WORKFOFlWNICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOFKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR <br />SUBCONTRACTING SIGNATURE CERTIFI THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKMAN'S CO H8 TION BOF ALIFO THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUDlEO fMSPECTK)NS. COMPLETE DRAWING BELOW. <br />!STONED % �, <br />TIT * <br />LE:�I DATE: <br />OT PLAN {DRAW TO SCALE) SCALE ' to <br />- NAMES OF STREETS OR "DADS NEAREST TO OR BOUNDING THE PROPERTY, <br />'2. OUTLINE OF THE PROPERTY, WITH DIMENSIONS AND NORTH DIRECTION. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, <br />INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON <br />THE PROPERTY OR ADJOINING PROPERTY. <br />APPLICATION ACCEPTED BY <br />ITANK, PIT OR SUMP INSPECTION <br />ADDITIONAL COMMENTS: <br />Pub. Health Serv.. Erniro. 174 (31W) <br />Si?-1'C•{�1.,^.4:!37•3 <br />