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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. 388,304 EAST WEBER AVENUE,STOCKTON.CA 5i 388 <br /> w (209)468-3420 -01 <br /> NON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED Ip:y <br /> IGmpkt*M T,pH-t.1 �s <br /> AfRICATION IS HEREBY MADE TO THE SAH JOAO COUNTY FOR A MRMR TO COHRTRICT ANDIOR INRTALL TIM~W DESCPoPED.THIS APRICAT1oN ro e1�E}N CPrM,'L/AMKE WITH MN <br /> '. JDAOVIN COUNTY DEVElOP1AEM TRLF,CHAPTER*-1110.3 ANO TIE STANDARDS OF SAN JOAGl11N COINTY PUALK HEALTH BERYK[*,ENNIIONMEHTAI HEAITH OMBIDN. 'C <br /> 'i c <br /> JOe <br /> ADM—A APN/./73441 -S.I.I 00 y/f3-ItO crrr .Skil, cit LpTeta.` <br /> owNER•a NAME Laver T.t eta LKcf.E ADDRESR /7� E. �/ / -r-/20 / �� ��, •H' <br /> CONTRACTOR /iyi'wirEs� c'/C7f.l�yv i(Y.�.0/.a�cl ADDRESRv (�Alc.((E/`8�3G� �1-�)!.S <br /> 6LIe eoNTRACToR AooPEr6 IL/TAN'F03 <br /> HIOrR <br /> TYPE OF EF1fIC WORK: NEW IN6i AlUTION❑ REFxwAOOHgN❑ DUITBLICDOM LAr <br /> ENG SEPTIC SYSTEM FTJ*rTTED F PUBIIC SEWER IS AVAILABLE WRHM 2W FEET OF SVI.Mj RRC—TI.1 I I HOW MANY <br /> AppE»bon <br /> INSTALLATION IVILL SERVE RESIDENCE❑ COMMERCIN❑ OTHER❑ <br /> MEMBER OF)MNG-T.:_ / NUMBER OF SEDROOMS: MlMA681 OF 9AROYEEI: <br /> CHARACTER OF SUR 70 A DEFTH DF 3 FEET' F"ISUAW SOIL CHARACTER WATER TABLE DEPTH <br /> *FDNC TAIRUOFTA TLAP ❑rYFEA.IFG CAPACRY HO.COMPARTMEHT8 <br /> PILO TREATMENT PLAIIT 11 tM6TANCE TO NEARFIT: WELL FOUNDATION PROPERTY LINE <br /> LIFT STATION❑ WE TYPE OF PUMP SAND OIL SEPARATOR ENCLOSED SYSTEM) _ <br /> IEACHNO UNE ❑ NO.\utwrm of L1NE8 DISTANCE TO NEAREST:WELL FOUNDATION —IFERTY LINE <br /> FILTER SED 0WIDTH LENCITH DEPTH DHHAHCE TO NENRST:WELL FOUNDATION I—ERTY DIW <br /> C\1 <br /> MOUNDED El WIDTH LENSTN DEPTH DISTANCE TO NFAFtEST:WELL FOUNDATION P KATY L14E <br /> SEEPAGE FHS ❑DEPTH SIZE MIMSER DISTANCE TO NEAREST:WELL FOUNDATION PFgFERTY <br /> SUMPS ❑WIDTH LENGTH DEPFH KIRTANCE TO NEAREST:WELL FOIMDADOH R1oPERTY LME <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL rOuHDATION PTIot'E RTY LINE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOM WSL BE LONE IN KCOROANCE WITH BAN POAOVIN COWTY ORD0,IANCE6 AHO STATE LAWS,AND RULE! <br /> AHD REGULATIONS OF THE*A/I JOADDM COUNTY.HOME OlWR OR LICENSED AGEHT'S SMDPAIVRE CERTEES THE FOLLOWINO:'I CERT"THAT IN THE PERFORMAI-f Of THE WOR(FORWHICH _ <br /> TME PERMIT IB ISSUED,1 SHALL HOT EMMOY ANY PERSON N SUCH A MANNER A8 TO BECOME SUBJECT TO WORKMAN-11 COMFEHSATION)AMA OF CALIFORNIA.-CONTRACTOTS IIvtI+O OR <br /> �ONTRACT/NG SIGNATURE CERTIFIES THE FOLLOWING:T CERHFY THAT IN THE PERFORMANCE OF HM WOM FOR WHICH THIS PEFV.IFT M BJECT ISSUED,1 8HALL EM"Y PER®GNS SUTO <br /> N[)RLMAN'*:co7mAION UWe CAIRO APRICANi MUST CALL H HCHIRII IN ADVANCE FOR ALL�REOUIFED INSPECTIONS.COUKETT DRAWRNG BELOW. <br /> BRiNEDX .� TELE: Syl A DATE" L� 7 <br /> PLOT PLAN DRAW TO SCALE)SCALE <br /> 1.NAME*OF SHEETS OR R0AD9 NF/JE8F TO OR BOUK"HO THE F MRTY. 4.LOCATION OF HOUSE SEWAGE DIBPOSILL SYSIEM OR PROPOSED <br /> 2. OUTLINE OF THE P"OPERTY.WITH DIMCHM"ANA NORTH DIRECTION. EXPANSION OF SEWAGE DISP08AL 9Y8TFMS. <br /> 3. OIMENBRIF/ED OU I INES AND LOCATION OF ALL EXISTING AND PtOMO D S RHCTVREB• S.LOCATION OF WELLS WITHIN RADIUS OF HE H OHDPED FIFTY 1T.ON <br /> N LI IND COVERED AFEAS SUCH AS PATIOS,DREVEWAY6,AND WALKS- TlE PFIOPERTY OR ADJDN*RI PROPERTY. <br /> PAYMENT <br /> RECEIVED <br /> z <br /> JILL -3 1997 <br /> sAN.IOA00IN-COUNTY........ <br /> ... .J_._PUBLC HEALTH SERVICES...... <br /> ENVIRONMENTALFiEALTH DIVISIOt <br /> 1FOR DEDIkATMMT VSE OMY <br /> AFfIXAT)ON ACCEPTED BY ` lay __DATE: ` ( ALFA: 1 <br /> TALK.PR OR SUMP NSPECTgHBy DATE <br /> . ,,,, ]�/-,(}L. �DAITT'EE S/ / FINAL WECTION BY DATE <br /> ` / <br /> - <br /> ADDITIONAL COMAEENi*:�1IV W�-�-� i- 4Lk Y •L"v_ �- <br /> ACCOUNTING ONLY: AID$ FACE <br /> R CODE FR 1NF0 ANIOIAV7 RD.MITED CIRCIV A8 RECOVFD*Y DATE M I M436+IFi Nl—m tNVOKF F <br /> o,/oa3s- <br /> Pub.Health SG .-EP iro.174(3196) <br />