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�l�VISOI+i?'.tE`,IT.�._ �l�1iSiDii p� (209) 463-3420 1 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED ICompbte in Triplicate) APPLICATION IB HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SEn"CES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNJ ��Z 52,� r T�V-AA1 A l,�A/ 44A I'J� CR/'Y' �J�`'4AQ'/^� LOT SIZE OWNER'S NAME S7-4 1- �D/V L/7 ADDRESS -7-41 pQ/��/V(/s C� JCJ-i L(/� _PHONE e3 e-74;2 rS CONTRACTOR cl-Y ADDRESS J f S I 1C A �tQ- L1C1 PHONE SUB CONTRACTOR ADDRESS UC/ PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RIEPAIR/ADDITION ❑ DESTRUCTION ❑ IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PERC TFSTNI f II HOW MANY 3 APPeoeeon f / Y J • J lJ/} INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL ❑ OTHER ❑ NUMBER OF LANG UMTS: NUINBER OF BEDROOMS: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANKJOREASE TRAP ❑TYPEIMFO CAPACITY NO.COMPARTMENTS PKG TREATMENT PLANT❑ INSTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR IENCLOSED SYSTEM) LEACHINO LINE ❑ NO.S LENGTH OF LINES DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE FILTER BED ❑WROTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE SEEPAGE PITS ❑DEPTH BRE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE BLIMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB•CONTRACTINOATURE CERTIFIES E FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM N8 TION LAWS O FORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUSRED INSPECTIONS. COMPLETE DRAWING BELOW, SIGNED X S/ TITLE': A ✓ 1p DATE: /.NT.(DRAWTOSCALEI SCALE1. NAMES OF STREETS OR ROADS NEAREST TO ORG THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON INCLUINNO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR AOJOINR 40 PROPERTY. _._• ! - _.. ... ..... ...... ..-_ _.. ..._. .. ._ ... ... .... .. .. ....... ... _. ... .. _ :. _.. _ ../.� .. .. .. ... ......... .. ... .:... -_. - - ... 11 _...... .:_. .. _... ...... - .. ..... ouft ... F9 C7vl pep c_T=sr _ J lica _ PAYMENT - � Pi it 1 o RECE:VFr). _. YA c c Nov : 61997 L P . SANJGAGUINCOUNTY __ 2G PUBLIC HEALTH Si:FVICD9 —N��f&. . _.. . ... i�lf FOR DEyAPTMENT USE ONLY -