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')U SAN JOAQUIN COUNTY PUBLIC'HEALTH SERVICES ENVIRONMENTAL HEALTH OIYISCOWNjoJ1, P.O. BOX 3b;304 EAST WEBER AVENUE, STOCI TQ,�q('95201,wl (209) 468.3429 `M,.P•ami NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS .L. (Complete In Triplicate) �""LIL.. yl'< APPLICATION IB HEREBY MADE TO THE BAH"AWN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL TIE W09L GEMMED. THIS APPLICATION to MAD(IrItiOENI 'MTH BAN "AWN COUNTY DEVELOPMEN `T /TITITU,CHAPTER 9.1110.3 O THE �OTA/N/DARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIM; RENTAL HEALTH DIVIMON. JOB ADDRESSIOR APINI 1/ _!YS /1 ;5 7 f-}/.0/G.1 _CITY LOT SIZE r/ OWNER'S NAME ADORERS 3 CONTRACTOR ~I ADORERS RIONE SUIS COMMCTOR ADOREBB W� T/ J /J� UDE RgIIE TYPE OF SEPTIC WORE: NEW INSTALLATION ❑ REPARVAD - Drmatia CTION❑ INR SEPTIC SYSTEM PERMITTED IF MnUC SEWER 19 AVAILABLE WITHIN 200 FEET OF BUILDINO.I PEM TFIiIFI L 1 NOW MANY INSTALLATION WILL SERVE: RESIDENCE❑ COMMERCIAL IJ(. OTHER ❑ / ( / ,{/� /� NUMBER OF IMNG UNITS:- NUMBER OF BEDROOMB: NUMBER OF BMPLOYEES:��/UU 7'✓C�'JS �rm,/ �LVCS Zti "T"a4�P CHARACTER OF SOIL TO A DEPTH OF 3 FEET: �pMRIUMP SOIL CHARACTER: / WATER TABU T E MI " SEPTIC TANEgREAeE TRAP 0TYPE,mF0 z7F✓l/terE CARACRY ��JCI / •y <1 iJ•ND,DOMPAR[MEMB / J /� ryLQ PEO TREATMENT PLANT 11 DISTANCE TO NEAREST: WELL 7I 00 FOUNDATION / PrgKE LINE UFT STATION❑ SIZE TYPE OF PUMP BAND OIL SEPARATOR IENCLOSFO SYSTEMI T LEACHING UNE yl`O.e LENGTH OF LINES DISTANCE TO NEAREST:WELL /fid FOUNDATION PROPERTY LINE S' FILTER BED ❑MDTII LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE MOUNDED ❑J WIDTH LENGTH 1{� DEPTH DISTANCE TO MEANEST:WELL FOUNDATION PROPERTY UNE SEEPAGE HTB y.yEPTH Z.5 SIZE Lfn /I NUMBER DISTANCE TO NEAREST:WED. FOUNDATION PIgFERTY LINE /0 SUMPS 11 WIDTH LENOTH OEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE DISPOSAL PONDS ❑MOTII LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPEAI Y LINE F V 1 HEREBY CERTIFY TIAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK MU.BE DONE IN ACCORDANCE MTN SAN"AWN COUNTY ORDINANCES AND STATE LAWS,AND RULES ANOREOULATIONSOFTHEBAN JOAOUINCOU .MO ME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOMMO:'ICERTIFYTHAT IN THE PERFORMANCE OF THE WORK FORWHICN THIS PERMIT I9 IBBUED.1 a.ALL NOT EMPLOY NY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKMAN'S COMPEN TION UNH OF CALIFORMA.' COMRACTOR'B H1mNG OR SUB CONTRACTING SIGNATURE CERTIFIES TH FOLLOWING'-1 CERTIFY THAT IN THE PERFORMANCE OF THE MRK FOR WHICH THI RMR IB IBBUED.1 SHALL EMPLOY PERSONS SUBJECT TO WV WMAN'S COMPENOATg. B ORW F CAU IA.' E PPIOANi MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED I PECTIONS. C/OM/PLyETE DRAWING BELOW. RIONEO X `� TITLE: [�e F/ �L: DATE: ROT PAN(DRAW TO SCALEI SCALE 't. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TILE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMISED 2. OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPOBAL BYBTEMS. 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 AREAE SUCH AS PATIOS,DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. 4 ///111 tP 41, E .. JAL /IL• { G��Th 'y��lt=E1 i,y1J �`�_��_ _ _ / �r ��,�/F/r' /r � r I;1 "okJT GY I.,joro v s ... 1 Int. 7 ..:. ..,..... tb _.. .... . .i... . .i... . .'. ... t ^ _ 0 WYyEN4.0 C ... ..........:.......5. .. ..i ...:.....:. a ... ...a �y 1. .. . MAY_2 3 1997... . 42 FOR DEPARTMENT USE ONLY AMJCAI*N ACCEPTED BY 1.4.L�L�-�-�/ �Y DATE: }ti ��3 9-7 AREA: a p TAM,AT OR BUMP INSPECTION BY / T DATE I I FINAL HIOPECTIOONN yBY- C�,�G/ZPV"'� -.T/J DATE S/p J-< Y� ADDITIONAL COMMENTS:�U LS e/ / L// .L SJ t LY I ' /'P�fL�L ��T 1e C4/ /•-L°d �� Elrr " -- bLO .:�fz-..Q• / / Pc7r .O /t...l e.,fP 4/v `e u.64 ACCOUNTIMO ONLY: AID# FACT pvl i'( '�/'LL C.� aC.Ca.{'/L PYP(/H.f•I//I'J MCODE FEE IWO AMOUNT REMII TEDIECE AMI RECOVED BY DATE eR I PERMIT NUMBER INVOICE nviro.174(3/96)