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SAYY—JOA-0UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH Of N <br /> `/ P O.BOX 388,304 EAST WEBER AVENUE, __-PCKTON,CA 95201388 <br /> (2091 4683420 <br /> a, <br /> PIONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (CBmpi tq Is Tr aliead) <br /> APPLICATION IS HEREBY MADE T THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION Ie MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPME TITLES HAPTEft 5-1110.3 AA TyH�E SJT/ANDAR 6 OF/SA JD/AOVIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/O / �/// ��/ / //�q!'�(' GL f�I CITY -yYr'�'[J LOT SIZE r2 <br /> OWNER'S NAME�1/�''wI l�L'1/N� L( ADDRESS O //�/^''��J / C,C,/�/' ��'C/�- J�RIONE l 11/ <br /> CONTRACTOR_` `L'1 �YL L � �J G- ADDRESS/Z/,c Cha l 7 /1 l LIC( C�� A10NF C ✓ '� 4� <br /> SUB CONTRACTOR AD.M.S LICI —ONE <br /> TYPE OF SEPTIC WORK: NEW INAIALLATION REPIJRIADDITION ❑ DESTRUCTION❑ <br /> IND SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVA LARLE WITHIN 200 FEET OF BUILDING.) PFRC TEBTI.1 I I HOW MANY <br /> APPII..d— <br /> INSTALLATION WILL SERVE: RESIOEN,COMMERGIAL T ER❑ <br /> NUMBER OF LIVING UNITS:_HUMBER OF BEDROOMS NUMBER OF ENIPLOVEE6: <br /> WATER TABLE DEPTH <br /> /�2LAR��. ER OF SOIL TO A DEPTH OF J FEET PIT/SUMP 60 CHARACTE �` <br /> SE' PT1C..rANK/OREA6E TRAP ❑TYPE/MFO CAPACITY �" ��-/ NO.COMPARTMENTS (tel <br /> PKO TREATMENT PLANT El DISTANCE TO NEAREST: WELL"T1[� FOUNDATIONS PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP/- SAND OIL SEPARATOR(ENCLOSED SYSTEM( ^ _ f <br /> .may^ L,[•L7� �i/L7-i_ L,FOUNDATION PROPEftiY LINE �L <br /> LEACHNO UNE KLNO.6 LENGTH OF LINES� DISTANCE TO NEAREST:WEL <br /> � <br /> FILTER BED /❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH �O LENGT'H/ DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> SEEPAGE PITS �DEPTHc<5! SIZE 7�/Z NUMBER(_DISTANCE TO NEAREST:WELLS GT' MUNDATIONi<5G / PROPERTY UNE �ZO <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE <br /> 1 HEREBY CERTIFY 1HAT 1 HAVE PREPARED THIS APRLICAT ION AND THAT T WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND ILEO S OFTHESAN JOAOUINCOVNTY.HOME OWNER ORLICENS AGENT'B SIGNATURE CERTIFIER THE FOLLOWING:'I IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THISRMR IS ISS D,I SHALL NOT EMPLOY R60N IN SUCH A MA A6 TO BECOME SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR <br /> SUB- ONTRACTING 61 NA RE CE 8 E FDLLO NO:'I CERTIFY TH T I THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WO MAN'S COMPENS TIO We <br /> OF 11 IFORNIA.' 1 LL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> /I TITLE: ��\ DATE: <br /> SIGNED <br /> PLOT PIA.(DRAW TO SCALEI SCALE <br /> 104. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 1. NAMES OF STREETS OR ROADS NEARES TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2.OUTLINE OF THE PROPERTY.WITH DIMENSIONS AND NORTH DIRECTION. 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES. THE PROPERTY OR ADJOINING PROPERTY. <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. <br /> -' ' <br /> ... G <br /> A,10 <br /> ' Jr <br /> .. <br /> ._ <br /> 1 <br /> FOR DEPARTMENT VSE ONLY <br /> "11 DATE: 4BY *AT—' <br /> AREA: <br /> AP CAl ION ACCEPTED BY -fDATE / - /TAN P OR SUMP INSPECTION RY DATE` / C / FINAL IN6PECTtO <br /> ADDITIONAL MMENT S: <br /> AID/ FAC. <br /> ACCO VNTIND ONLY: _ <br /> PE CODE FEE INFO AMOUNT REMII TED CI ECK/CASH RECEIVED BV DATE BR!PFAMIT NIIN@ER <br /> M <br /> INVOICE/ <br /> I Il`7 0. co <br /> Pub.Health SON.-Enviro.174(3196) <br />