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SAF' RUIN COUNTY PUBLIC HEALTH SERVICES I <br /> IVIROMMENTAL HEALTH DIVISION <br /> P 988,904 EAST WEBER AVENUE,STOCKTON,CA,OM1388 <br /> (20111408-3420 <br /> ` N01-REFUROAILE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED — �( <br /> R•EePMb IPM <br /> IN TrEto f)9 <br /> APPLICATION IB 1 A .THE BAN"ADM COWIFY FOR A FEIEAR TO CONBERMT ANpgR IFLBTALL THE WORK ME MBED. THIS APR1CATroN IB MADE IN COMPLIANCE WEEN RAN <br /> "AWN COUNTY DfMOMENT TITLE,CHAPTER 9.1110.'3 AIA STANDARDS OF RAH"AGMCOUP PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVIMON. <br /> JOB ADDRINSMIL ANN, C.'G/ M4 C44. cj ciA„ /�9'eq Cm <br /> OWNER'S NAME_( i�A L//7��..V..FLr,.EE4 ADDRFee YH�/'I/t.A!- RroNE /• V L 1 <br /> CONTRACTOR `/)/A-! bne ADDRESS <br /> / ✓�l/G/�� � _,y / UCI PHONE <br /> RUB CONTRACTOR. <br /> TYPE OF SEPTIC WORK: MFW INRTAUJkTION❑ RE9IegMpLATN1N DEAtR11CT10N ❑ <br /> IND PEPTIC SYSTEM REMITTED N LIC PUBFEWER IR AVAILABLE WITHIN 200 FEET OF RUAFWNj PERC TESTI.)I I NOW MANY <br /> [: <br /> 10 <br /> ArMe.tlen <br /> INSTALLATION Will SFgVE R6IDENCE 11COMMERCIAL OTHER ❑ <br /> NUMBER OF LIVING 1)MTR:-_ RUSIONS OAF BFd100}FB: NIIMR9L OF BAROYEEB: --E <br /> cIUMCIFR OF 601E TO A DEPTH OF]FEEF/J^/Y'1/ PIT/BUMP ROPE CHARACTER: WATER TABLE DEPTH ; -c Y- <br /> SETOC TANKJOBFAAE TRAP ❑FYPE/MrO CAPACITY NO.COMPARTMENTS <br /> FIND TREATMENT MMT❑ DISTANCE TO NFMFIT: WELL FOUNDATION PROPERTY LINE <br /> RIFT STATION❑ SIZE TYPE OF PUMP RANO OR SEPARATOR RNCLO6Ep SYSTEM) <br /> !' 1 <br /> lEAC11N0 UNE NO.•LENGTH OF IMEB� �CI INSTANCETONFAl1EST:WELy-9R FOUNDATION !/ • RTroPERTY LINE <br /> FILTERSfD /❑WIRTH LENGTHY DEPTH DISTANCE TO NEAREBE:WELL FOUNDATION RoMory LINE <br /> MOUNDED 11WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PWI TY LINE <br /> SEEPAGE RTO ❑DEPTH RAZE - NUMBER DISTANCE TO NEAPEer:WELL FOUNDATION PROPERTY LINE <br /> 6UMP8 ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION ROPERIY UNE <br /> DISPOSAL"Not E3 WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> 1 HEREBY CERTIFY TIUT 1 HAVE MPA D TIPI9 ARY4ICAT ION AND THAT THE WORK WILL RE DONE IN ACCOMANOE WITH BAN JOAOUIN COUNTY ORDINANCES AND Or AT UWP,AND M)1 EB <br /> REOVIAFIO TIRE BAN JpA0U1 COUNTY.HOME OWNER ORUCENBED AOEM'S SIONAIIIRE CEIITIIRB TIIEfOLLOWING:'ICERTIFYTHAT INTNEPEMOM/ANCF OF TIREWIIRK FOR WPIICN <br /> TMB MI IB ISRUE0, SHALL HOT E OY AM PERSON IN SUCH A MAMMA AN TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAW*OF CALIFORNIA.- COMRACTOR'O NIRNO OR <br /> PUB CO IND SI TURF CERTW THE FOLLOWING:'I CERFITY THAT IN THE RRFOIMAANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS OVBJECT TO <br /> WOIKM C LAWS O ALIFORNIA.' THE APMJC M MWT CALL 24 MMI IN ADVANCE FOR-AL(L���R,EADUxREp INRPECTIONR, COMPLETE IIMWING BELOW. <br /> fit. <br /> \\O x I / ( TITLE: ( -v DATE: �• Y 1 <br /> PLOT MN RMAW TO SCALED SCALE •Is <br /> 1. NAMES OF STREET MADS NEAREST TO OR BOUNDING THE PROPERLY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL RYSTFM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,WITH DIMENSIONS AND NORTH DIRECTION, EXPANSION OF$MADE DISPOSAL SYSTEMS. <br /> 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED RTMCTUREB, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WALKS. THE PROPERTY OR ADJOINING Prod '. <br /> 5'o <br /> Vt ao — T <br /> vuel.iL HF,Li rL )E �c; <br /> DEPARTMENT USE ONLY <br /> AI'RICATIONACCMEORY y' V{ ` / W"��/\� GATE: L I AIIEA: <br /> TANK,RI Ofl M INSPECTION O 1 - DATE FINAL INSPECTION BY <br /> ADDITIONAL COMMENTS!� .^^Jl 1"'•' <br /> ACCOUNTING ONLY: AUR FACT <br /> IF CODE FEE INFO AMOUNT gFMll iFO ITEC A RECDVED BY DATE SR/PDYAIT NUMBER INVOICE I <br /> Pub.Health Serv.-ETWIro.174(3/96) <br />