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10/05/2004 15:25 4640138 ENVIRONMENTAL HEALTH PAGE 04 APPLICATION FOR LIOUIO WAS 'RMIT SAN JOAOUIN COUNTY PUBLIC HEAM SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 3813,304 EAST WEBER AVENUE,ST'OCKTON,CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TFIpReatf) AFPUCATION IS HFPFRY MARE TO THE,BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INET ALL THE WOW DESCRIBED, THIS APPLICATION 10 MADE IN COMPLIANCE WITH CAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1110.3 AND HE STANDARDS OF SAN JO IN COUNTY PUBLIC HEALTH 6�E/g(/y�IC�ER,ENVIRONMENTAL HEALTH DIVISION_ JOB ADDREPS/ORCAaa�.//� (� - �k, CITY �/ 'C�'�-7YO LOOT SIZE Q�G� OWNER'S NAME ( /i/T� ��J�L ADDRE97 �(!L PHONE�C'JS/-4/7 / CONTRACTOR-/ 0A IT� AODREPSLZ I CC l-/WC ,'I( �/�L LICITT PIONE�CL-� y� SUBCONTRACTOR ADDRESS UC/ PHONE TYPE Of-4P11C WORK: NEW MSTAWT70N REPADVAODITION ❑ bif TRUCTION❑ NO SEPTIC SYSTEM PERMITTED IF PURLIC SEYJFR IS AV ILARLE WITHIN 700 FEET OF RUILDINGJ C SERC TFSTW(1 HOW MANY AFP11-0 n/ INSTALLATION WILL tFIIVE: RIDENCE❑ COMMERCIAL❑ OTHER SC A7 NUM.ER OF LMNO UNIT.: nRAuf wR OF SEOMooM.;_ NUMBER OF FMPLOYEEf: C OF ROIL TO A DEPTH OF J FEET A. WIC. S.O_IJL CHARACT //�� WATER TABLE DEPTH �� 1 ►TIC TAN PASS TRAP ❑TYFEnA TO AVLC4(� `•� i�f�CAPACTTY LS1OD P+D.COMPARaM ••�,., Zll PKO REATM ENT RANT 0 DISTANCE TO NEAREST: WELL L LIOP_ FOUNDATION P"PEATY UNE ate%I UFT STATION❑ SyITE TYPE OF RIM'S IT^SAND OIL SEPARATOR(ENCLOSED BYSTEMI LEACMMO LINE >11-NO.a LENGTH Of LINES �`X10 (T DIST ANCF TO NEAREST:W21L�FOUNDATION (Cl _P"O ERTY LINE / FILTER BED /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PHOMPTY LINE MOUNOED ❑WIDTH LENGTH DFPTN DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LME •-� �_ FOUNDATION (� PORTY L IEIME1- SEEPAGE PITT SIZ �DERFHE 7(0 1� NUMBER DISTANCE TO NEAREST:WEtI SUMP{ (E❑E_•�R WIOTH LENGTH DEPTH DISTANCE TO NEAREST:WEU _TOUNOAmw PROMV"UNE S- D19MOAL POND. 4J WIDTH LFNOTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE S Q I HEREBY CERTIFY THAT 1 HAVE PIEPAREO THIR APPLICATION AND THAT THE IFC WILL BE DONE M ACCOflb ANCE WITH SAN JOAMIIN COUNTY ORDINANCES AND STATE LAWS.ANO PULES 4 AND REGULATIONS Of THE BAN JOAQUIN COUNTY.NOME OWNER OR LICENREO M•9 SIGNATURE CERTIFIES THE POLLOWINO:-1 CERTIFYTHAT IN THE PCAFOPMANCE 01 THEWOFK MnWHICH THIF PERMIT 19 ISSUED,I SHA OT EMPLOY AF PON IN SVCH A MANNE AS O BECOME SUBJECT TO WV KMAMB COMPENSATION LAWS OF CALIFORMA.• CONTRACTOR'S NIRMO On SUA•COMTRAtTING SIGNATU £C MIES' OLLO O:'I CERTIFY THAT I THf, PFORMANCF OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PR.ONB SVPIFCT TO WORKMAN' OM SA ION WI3 OF A F IA,- T APPLICANT MUST ALL 2A Ulf IN ADVANCE FOR ALL REOl11NT WSPECT1ONf. COMPLETE DRAWING BELOW. SIGNED X TITLE- /Lr DATE: ROT DUN(DRAW TO SCALER SCALE.'Ie T, NAMF,B OF STPEETS S NERE OR ROADAST OR SOUNOW.T.1PROPERTY. A. LOCATION OF"OUSE SEWAGE OI.PO9K SYSTEM ON POM-FO I 2. OUTLINE OF THE PROPERTY.WIT.DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SFWAG!DISPORK SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF AU.EXISTING AND PROPOSED STRUCTURES, S THE IGIATION OF OR ADJOININGIADMI of CNE RE HUNDD FIFTY PT.ON LUP—THIN PnOrEPmF INCLUDING COVERED AREAS SVC"AB PATIOS.DRIVEWAYS,AND WALX9. : � j &j . . - ..,.......: .......... :.....:.....: a v. .. .. 3b1g . . ...... :: . ..........:. p. T, l.� -All , i ip rIN 419 c .........:. . .. � p j V H�LTH S1�E:'S _ _� .........:... •..ENVIRONMFtNTkL r.F%?M FOR DEPARTMENT UAE ONLY _AREA, DATE: p APPLICATION ACCEPTED BY DATE I?b I Ya LATE / I FINAL INSPECTION I e TANK.PT OR RUMP INRP`F,CTION By AbOIT10NAL COMMf,NTS: FAGS ACCOUNTING ONLY: AID/ ATE PE COLE PEE INFO AMOUNT REAITTFp 311f H RET:EVED ST I P/PEERNIIT NU.RBER INVMC!/ 10/05/2004 TUE 14:57 [T%/RR NO 76101 Q005