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11110111114 — DOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICAT I)N IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TrrLE,CHAPTER 9-1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICCE'S,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNi_! / �G` '� -, ! / • �'i L<y�, /CITY `t^ /~�-k-'tl �S LOT SIZE_/ OWNER'S NAME - G ADDRESS/( �L 7 / 7L r L!/�p� CONTRACTOR ADDRESS��X /� L- z. 1/-7 /-1 // , MrA LICA 1 zPHONE'3C=' SUB CONTRACTOR ADDRESS UCI PHONE TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ f/] ;NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PSRC TESTIS)( 1 HOW MANY {� Appli–non r INSTALLATION WILL SERVE RESIDENCE COMMERCIAL ❑ OTHER ❑ NUMBER OF UVINO UNITS. NUMBER OF B/EDROO//M__S__: NUMBER OF EMPLOYEES: CHARACTER OF SOIL TO A DEPTH OF 3 FEET-��-, f-�A- PR/SUMP SOIL CHARACTER: WATER TABLE DEPTH SEPTIC TANK/GREASE TRAP ❑TYPE'MFG CAPACITY NO.COMPARTMENTS PKO TREATMENT PLANT ❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) :EACISNO UNE ❑ NO.&LENGTH OF UNES DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE FILTER BED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNOED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE SEEPAGE PITS ❑ DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑WIDTH LENGTH_ DEPTH DISTANCE TO NEAREST WELL FOUNDATION PROPERTY LINE I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS 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-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLJC ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOLSRED INSPECTIONS- COMPLETE DRAWING BELOW. L- V a /ZGL/'DATE: SIGNED X r/ � � �--��C - �-C-+-' L-- TITLE: C�/��/ f PLOT PLAN(DRAW TO SCALE)SCALE "To 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING 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 INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. OWNER NOTES' a 1.)Prosect Description' +�Sii LKM_ 2.)Utillties a Facilities' r .• a Wotu SUDDIy' Sonllotion sflc •nsw St—orainoQe. Electriclty- .c •.. Gov /1 Tol•pocor na•-s+ca fir 2 t ee WFloodinq Information' 5.)Property Address' nn.•<.,.-ro,c.+..ar• w t 'J ow z Aej 4 C3- C 71-LfJ W } O 2 i-- vyICINITY�MAP c 2 <mS U) I a� LA;