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(209( 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION 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 <br /> JOAQUIN COUNTY DEVELOPMENT. % S <br /> TTIITLEE,CHAPTER 9-1.1110.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, AL S,ENVIRONMENTHEALTH DIVISION. <br /> JOB ADDRESS/OR APNF_..2n / /1R()/ 1z CRY LOT SIZE <br /> /P^ <br /> OWNER'S NAME /(',x <br /> 1tT^h_t,/STh�/���L/]�{� /-tJ ADDRESS �7 I /p <br /> CONTRACTOR �ri ] U^C ICAd{ ADDRESS/•O•��n /Q�Z_ r'Q,C4,7r,�g,1,'A UC# ar'/'3y PHONEr'06`'�7YY:lS <br /> '-SUB CONTRACTOR ADDRESS LICE RHONE <br /> TYPE OF SEPTIC WORN: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 0( <br /> _(NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVAILABLE WITHIN 200 FEET OF BUILDING.) PEIO TEST W I 1(HOW MANY <br /> AppRoadon <br /> M <br /> INSTALLATION WILL SERVE;: f1ESIDENC� COMMERCIAL ❑ OTHER ❑ <br /> NUMBER OF( NG UNITS: NUMBER OF BEDROOMS:J a NUMBER OF EMPLOYEES: <br /> CHARACTER OF SOIL TO A DEPTH OFF 3(FEET: c.PIT/SUMP SOIL CHARACTEN WATER TABLE DEPTH <br /> SEPTIC TANR/OREASE TRAP ,{y TYPE/MM r&k C XC& P/C.. CAPACITY /L-UJ NO.COMPARTMENTS <br /> PCO TREATMENT RANT❑ DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> UFT STATION❑ SIZE TYPE OF PUMP S OILISEPARATOR(ENCLOSED SYSTEM) <br /> LEACHING DNFNO.i LENGTH OF LINES t DISTANCE TO NEAREST:WELL ef� r FOUNDATION 16 Y PROPERTY LINE �a r <br /> FILTER SED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY LINE <br /> MOUNDED ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATIONT PROPERTY LINE <br /> —SEEPAGE RTS �DEPTH �S • SIZE �z , NUMBER Z DISTANCE TO NEAREST:WELL/6V' FOUNDATION 'a` PROPERTY UNE /G t' <br /> SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY UNE <br /> DISPOSAL PONDS WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELLFOUNDATION PROPERTY LINE �- <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES AND STATE LAWS,AND RULES <br /> AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER ORUCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT IN THE PERFORMANCE OF THEWOPC FORWHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WOPCMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR <br /> SU&CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> r OPXMAN'S COMPENSATION LAWS <br /> S/�OF,CALIFFORNIA.- THE APPLICANT MUST CALL N HOURS IN ADVANCE FOR AyALLL'REQUIRED INSPECTIONS. COMPLETE DRAWING BELOW. <br /> -SIGNED X TITLE: DATE: /Z -T <br /> �C J;--! (V [__ tl� l/!� <br /> G <br /> r PLOT RAN(DRAW TO SCALE)SCALE -to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 1 <br /> t. OUTUNE OF THE PIbPERTY,WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, T ` 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.ON <br /> INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. K k)6' <br /> PROPERTY OR ADJOINING PROPERTY. <br /> G <br /> klet <br /> _ k <br /> ICI �'�'°`� T'•E 0. ata Fes' <br /> d <br />