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QQ SAN RUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 "1YIRONMENTAL HEALTH DIVISION <br /> PA.BOX 3K 3L.-EAST WEBER-AVENUE.STOCfCTON.CA SS201-388 <br /> (2091469-3420 <br /> NON-REfURDAUIE PERMIT PIRES 1 YEAR FROM DATE ISSUED <br /> 4L1NRpIBtB in TEilpliatB) <br /> APFT.ICATIOk IB HEPLBY MAOI TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANUATR INSTALL THE AMnK DESCRIBFD,TRIS APPLICATION IS MADE IN COMPLIANCE WITH BAN <br /> - JOAQUIN COUNTY WILL CHAPTER O 1110;- AND THE STANDA${IS Q�'pAN JOAOVIN COUNTY PUBLIC HEALTH SERVICE$,E�MENTAL HEALTH DINSION. /� <br /> JOB AOARESB/Dfl �ryCl lNYwfrA'� 1{A/— —CITY 'LOT 81 II7•� (JCI <br /> OvnTER'S NAMEE^ -a' / TTh'�-�.� A170f5EBB R7oNE f G/ <br /> CONTRACTOR ADORES$ 11CI PRFGHE <br /> SVB CONTRACTOR ADORERS LICS NIOHE <br /> TYPE of 6-10 WORK: xEw INSTALLAROx❑ REPAIFUADtriTION❑ DEFTRwT/ON❑ <br /> ` WO SEPTIC SYSTEM PERMTI'TEO IF PUBLIC SEWER 18 AVAILABLE WITHIN 200 FEET OF BVIIOING-I /BtC Tt'sTHI f I HOW MANY <br /> ! Appbatlan i <br /> 'INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL❑ OTHER EI <br /> NUMBM OF LlV110 UNITS: NUMBER OF bEDROOMS: NUMbFR OF"PLO"": <br /> CHARACTER OF SOIL TO A DEPTH OF 33 FEET: FMSOMP SOIL CHARACTER: WATER TABLE DEPTH <br /> I SEPTIC TANKMOREASE TRAP 0TYPFJMFO CAPACITY NO-COMPARTMENTS <br /> PKQ TREATMENT PLANRES <br /> T 0 DISTANCE TO NEAT: WELL FOUNDATION PROPFRTY UNE <br /> LWT STATION E3 612E TYPE OF PUMP SAND OR SEPARATOR IENCLOSED BYSTFMI <br /> S LEACHING LINE ❑ NO.S.LENGTH OF LINES DISTANCE TO NEAREST!WELLFOUNDATION PRDPERTY LINE <br /> RLTFR BEA ❑WIDTH LENOTN DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE CJWI <br /> I O <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCETO NEAREST!WELL FOUNDATION PRAPERTY LINE <br /> BEEPA01;RS D T)E <br /> RTS SIZE - NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> SUMPS ❑WIDTH LENGTH UEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> DISPOSAL PONDS (3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED TMS APPLICATION AND THAT THE WOW WILL OF DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES ` <br /> ANGREOULATIONBOFTHE'AN JOAQUIN COUNTY.HOME OWNER"LICENSEDAGENT'SM1'IATURECERTIFIES THE FOtLOWINOITCEJRIFYTHATINTHEPERFORMANCEOFTAX WOFKFORWHICH O, <br /> THIS FERMFr IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBIECTTO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR 3 <br /> SVB-CONTRACTING BIGNATURE CERTIFIES THE FOLLOWING;Y CERTIFY THAT IN THE PERFORMANCE OF TNT WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WOPKMAN'S Co <br /> r N LAWS OF CAUFORNIA.-THE APPLICANT MUST CALL.24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS.COMPWE DRAWING BELOW. <br /> SIGNED TITLE• <br /> Fes^^ PLOT PLAN(DRAW TO SCALE!SCALE.*0 <br /> 1.NAMES OF ST OR ROADS NEAAEBT TO OR BOUNDING THE PROPERTY. 1.LOCATION OF HDUBE SEWAGE DrWUSAL SYSTEM OR PROPOSED <br /> 2'OUTLINE OF THE PROPERTY,.WITH DIMENSIONS AND NORTH DLRECTION. E%PANSION OF SEWAGE DISFOBALI SYSTEMS. <br /> 1 3. DIMENSIONED OUTLINES AND LOCATION OF ALL DUSTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN IIAONB OF ONE HUNDRED HFLY FT.ON <br /> INCLUDFNO COVERED AREAS SUCH AB PATIOS,OlSYEWAY3,AND WALLS. 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F JBLIG HFALT�S!RVI( ...,.. <br /> ....... <br /> ....... ...... �f�V1ROhMiJTkL HEAL ©I,u15kQ <br /> .............. <br /> ...... <br /> .. .........:.... <br /> FOR OWAATMENT IME ONLY <br /> —rATRON ACCEPTED BY DATE' - AREA: �( <br /> TANK.PT OR SUMP INSPECTION SY <br /> ATE ! / FSNAL INSPECTION BY GATE f T ! <br /> ADDITIONAL COMMEITTSc_ <br /> I <br /> EACCOUNTING ONLY: AID! FACR <br /> ♦1 CODE FEEIWO AMOUNT RENI ITER NEC !CASH ROCDVED BT DATE SR IPLIIMIF NUMam INVOICE IF <br /> 0 D374,9 <br /> Il <br /> Pub,HABUh Serv.-Enviro.174{3186} <br /> i <br />