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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,904 EAST WEBER AVENUE,MCKTON,CA 95201388 <br /> (209}469-3420 <br /> NOR REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> lllt C �� c�� 1�y, RPad Ip TrlPlkanl <br /> APPL)CATKW IS HFAEOY MADE TO THE SAN JOAQUIN COU FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MAGE M COMPLIANCE VVIT'A SAN <br /> JDADUN+COUPRY DEVELOPMENT TLTLE,CHAPTIDI S•1110.3 AAJ�NO�THHEE.S..TAN(OVAA]OB OF SAN JOAQUIN COUNTY PUBLIC HEALTH 9Sy/nEEJpgTWLy,ES,ENV) MENTAL HGALTTT OmswM IYl <br /> JOBADdE58JOR APN/_ 9T3 C2�` CRY.N- ./ LOT 8VE_ <br /> OWNWS NAME -'j� N�i.0 ADDAE88 PHONE <br /> a // <br /> CONTPACTOk Z. UC/7�ONE I//_�L64 49 1 <br /> SUBCONTRACTOR ACORESB LK/ PHOM;. <br /> "fE OF SEPTIC WORK: NEW INSTALLATION❑ REPAINAODITION DEITRVCTION❑ <br /> I NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAAPSI.E WITHIN 200 FEET OF BUILDING.) PEIC TESTPI i I FLOW MANY <br /> may[// APFSP06PR/ <br /> INSTALLATION WILL SOWS. RESIOEN.^.E L� COMMERCIAL❑ OTHER❑ <br /> NlRliq OF LIVING UPST S: I NLRTSEN Of SEDRWOMS: NUMBER Of BAPLOVEES: J <br /> CHARACTER OF SOIL TO A bEPTTH OF J FEET: PITMUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> SEPTIC TANK9W4UME TRAP ❑TYPEMIFG CAPACITY NO.COMPARTMEMO <br /> PECO TRATMEIT KANT❑ dSTANOE TO NExmor; WELL !!%//T f VNAATION PROPERTY UNE220� <br /> OFT STATION❑ SIZE TYPE OF PUMP_SAND OIL SEPARATOR IENCLOSED SYSTEM) <br /> _ <br /> IEACHINO UNE X NO.&LENKITH OF LINES V DISTANCE TO NEAREST;WELL�LN_ FOUNDATION _PIWF'EFTTY UNEP <br /> rMTER Sm ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LAVE <br /> MOUNDED ❑WfDTHLENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE�_�, <br /> SEEPAGE PITS 13 DEPTH _wE. NUMBER <br /> DISTANCE TO NEATEST:WELL FOUNDATION PpORERTY LWE .7.[� <br /> SNP► ❑w10TH LENGTH__DEPTH DISTANCE TO NEAREST:WELL FOVNOATK)N PROPERTY LANE <br /> DISFOSAL PONOS ❑VAOTH LENGTH__OEPTHDISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> - <br /> I HERESY CERTIFY THAT I HAVE PREPAFE0 THIS APPLJCATKFN AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN J'JAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES <br /> ANO WOULAT10NS OF"11ESAN JOAOINSI COUNTY.NOW OWNER OR UCENSED AGENT'S SIGNATURE CERTULES THE FOUjDWWD;'I CEATIFYTHAT M TME PERFORMANCE OF THE WOFN.POR WISCH <br /> TFMS PERMIT IB IIISVED,)SHALL NOT EMPLOY ANY PERSON RN SUCH A MANNER AS TO BECOME SUBJECT TO W W MAN'S COMPENSATION LAWS OR CALIPORFBA.- CONTRACTOR'S HWM OR <br /> SUB,CONTRACTIND SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTFWY THAT M THE PERFORMANCE OF THE WOW FOR VASCH THIS PERMFT IS ISSUED,1 SHALL EMPLOY PETBONS SUBJECT TO <br /> NbiKMAWS(C�O"�MP'ENNSSSAAT'G.--WS Df LNOFW ' THE APPLICANT MU►T CALL 24 HOURS IN ADVANCE FOR ALL REOIIRED INSPECTION$,COMPLETE D'PAWWO BELOW <br /> SIGNED x 71+- 7 I t � C / TITLE:(..,^, DATE: <br /> PLOT FLAN iDRAW TO SCALE)SCALE <br /> 1.NARES OF STREETS OR ROADS NEAREST TO LFR LJ <br /> SONIMNO THE PROPERTY. 104.LOCATION OF HOUSE SEWAGE OIOFDSAL SYSTEM OR P90POSOO <br /> 2.OUTLINE OF THE PgWITH DIMENSIONS AND NORM DIRECTION- EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> S.DIMENSIONED OLITUNES AND LOCATION OF ALL EXIST ING AND PROPOSED STRUCTURES S, S.LOCATION OF HELL!1T6'R/IN RADARS OF ONE NIJNORED FTgyFT.ON <br /> INCLUDING COVEPED AREAS SUCH AS PATIOG,ONVEWAYS.AND WALKS. INE PROPERTYOR ADJOINING MOPERTY. <br /> 14 Q 4 T . .. <br /> �>� -- <br /> . 5 <br /> pool <br /> R 1 X59 <br /> FOFy DEPART�I IT USE ONLY <br /> ' <br /> f <br /> i <br /> APPLICATION ACCEPTED BY I 1•N DATE: <br /> T f4T cLR 8UMP INSPECTMJN SY UATE 7 G )NAL W SPECTION V DAT <br /> E <br /> D9R1C[0JN'JAL,COMMEMS- / L <br /> ACCOUIITINO ONLY: AID/ FACC <br /> F.T CODE PLl INFO AMOUNT RDW ITED CHECK/ H MECENED IN DATE m I PBV.IIT NUMBER INVOICE/ <br /> , r S1-,6b t 010(o Sha <br /> Pub,Heatth SUN.-Elrviro.174(3+96) SIR O O 1 g S g S <br />