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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES � ENVIRONMENTAL HEALTH DIVISION vtJ'Ilc' '- PA BOX 388, 304 EAST WE13ER AVENUE, STOCKTOM, CA 35201988 (2091468-3420 WON -REFUNDABLE PERWT EXPIRES YEAR FROM DATE 19911E 1Cempiau IS TripERata) APPLICATION IS HEREBY MADE TO THE IAN JOAOURN COUNTY FORA PERMiT t0 CONSTRUCT ANOIOR 04ST"ALL THE WOW DESCFMFD, THIS APPLICATION IS MAOI N COMEUANCE Wrfi1 IRAN JOAQUIN COUNTY DEWLONJENT TITLE CHAPTER 2-11 iD.3 AHD THE STANDANbe OF BAN JOACIRN COUNTY PUBLIC HEALTH SERVK*"NVIROIISRNTAL HEALTH OMSIOM, Cl LOT 81:E 1pfb OWNER .+�-8 NAME A� 77 Z--- e//�L lS .� ADDMS9 Z-.. - T 6 -%� T7 G!i r!'1 SUBCONTRACTOR ADDRESS UCS EHOWE TYPE OF awm WORK: NEW INSTALLATION ❑ REPAaVADdnO DESTRliCT1oN ❑ FNG &EPTLC SYSTEM PERNOTTED IF PUBLIC SEWER IS AVAAABL.E WITHIN 200 FEET OF BURLNNGJ P91C TESTW 1 140— MANY Appamior• • IN/TALIATION VALL SHM NC 91DFNCE YL COMMERCIAL ❑ OTHEH [INUMBER OF UtAND VATS: NUMLLLIM INF BEDROOMS: � MtNASSt OF BMPLOYFEA: CHARACTER OF SOIL TO A DEPTH OF 3 FEET: ,/SAT/SUMP SOIL CHARACTER: y� WATER TABLE DEPTH SEPTIC TARElaRE SE TRAP ❑ TYfE1MC�.�/ CAPACRY j✓4 � NO. COMPMT}.1 _/2 I MO TREATMENT PUNT ❑ DISTANCE TO NEAP14T: WEU fOLRNOATION PROPETTY LINE UFT STATION ❑ RDF TYPE OF PUSM SAND Olt SEPAILA FOR IENCLOBW SYSTEM LEACHINO LINE ❑ NO. A LENGTH OF LINES_ DIBTANCETD NEAREST; WELL FOLNNDATION PROPERTY LINE RUST BED ❑ LIDTH tENOT14_ DEPTH DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE YDUNOM ❑I��L WIDTH LENGTH DEPTH DISTANCE TO NEAREST: WELL FOUND/ MN PROPERTY UNE M SE PAPITS U DEPTH KZE NUMBER DEBWR T ASCE TO NEAREST: WL f0UK'OATION PRDPEREY UNE %UlMPB 17 WIDTH tENOTH � DEPTH OISTANCETO NEAREST; WELL FOUNDATION PROPERTY LINE DISPOSAL PONDS ❑WIDTH LENDtH DEPTH DISTANCE TO NEAREST: WELL!-OtMATRIN PROVO" LNE 1 HOIEBY CERTIFY THAT I HAVE PRREPARMD THIS APPLICATION AND THAT THE WOIK WILL BE DONE IN ACCOMANCE'ATTH BAN JOAMXN COUNTY ORONANCES AND STATE LAWS, AND RULES AND REOULAIMS OFTHE BAN JOAOUIN COUNTY. HOME OWNER OR LICENWO AGENT'S SIGNATURE CERTIFIES THE FOLIO WINO. 10EATIFY THAT IN THE PERFORMANCE OF THEYVDAN FOR WNIGH TMS PEpAFF IS MWJEO, 1 SHALL NOT EMPLOY ANY PERSON N SUCH A MANNER AB TO BECOME SUBJECT TO WDE[MAN-S C JAIPENSATION LAWS OF CAUrOMNIA.- CONTRACTOR'S FIgRNI OM1 "L CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: 'I CfFTOFY THAT IN THE PERFORMANCE OF THE WOM FORYJHICH THIS PIDIMIT IS ISSUED, I SHALL EMPLOY PERSOM SUBJECT TO WORKMAN'S COMPfNRATIM LAWS OF CAL"MRA." THE APKW UST CALL N HOURS IN ADVANCE FOR ALL REO.tARED INSPECTIONS- COMPLETE DRAWNNO BELOW. SPBWO X / t F. ! / TITLE: l.(/ 11 DATE- PILOT ATEPILOT PLAN IDRAW To SCALL) SCALE T I. NAMES OF STREETS OR ROADS NEMIEST TO OR BOUTIDNG THE PROPERTY. L. LOCATION OF HOUSE SEWAOE D3SPO8AL SYSTEM ORLVED Z. OUTLINE OF TNF PROPERTY. WITH DIMENSpows AND NORTH DIRECTION- EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. ONAENBIDNED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED "RUCIUREC, i. LOCATION OF WELL8 WITHN RADIUS OF ONE WA40RED FIFTY fT. ON INC1,00M COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. THE PROPERTY OR ADJONyM PROPERTY. /i fJ r hVn APPLICATION ACCEPTED BY I -.. V V TAM(, A7 OR SUMP INBPECTgW BY AODRIONAL OIDNOAENTS: ACCOONITNLO ONLY: PE CO9E EEErNCFO ANgLNF REAI1 TID USE ONLY I AID# 1 FACT Pub. HBBRH Serv. - Enviro. 174 (3)86) 1 ILLS I RECDVED 81 I DATE I SRI PEPAT NUMBER S 1